Coping with the unforeseen in surgical work Pieter Jelle Toussaint

Line Melby

Norwegian University of Science and Technology IDI Sem Sælandsvei 7-9 NO-7491 Trondheim + 47 735 50739

Norwegian Centre for Electronic Patient Record Research MTFS NO-7489 Trondheim + 47-73551536

[email protected]

[email protected]

ABSTRACT Clinical work is highly contingent. Within the boundaries set by plans, guidelines and procedures, clinicians apply several strategies to cope with unforeseen events. IT support must not be aimed at reducing or even eliminating these unforeseen events, but at supporting health personnel with coping with them. In this paper we will illustrate how requirements for IT support can be derived from investigating how formal strategies for coping with the main challenges in surgical work break down in the face of unforeseen events and the informal, ad hoc strategies that are applied.

Categories and Subject Descriptors H.4.1 [Office Automation]: workflow management. H.5.3 [Group and Organization supported cooperative work.

Interfaces]:

computer-

General Terms Human Factors, Management.

Keywords Clinical work, Interruptions.

1. INTRODUCTION Many sources characterize clinical work as highly contingent ([1], [2] and [3]). Although plans and guidelines are important resources in executing and coordinating work, the actual course of events is far from determined by them. For this reason it is difficult to fit in traditional workflow systems as support for clinical work. There are different approaches one can take in designing clinical process support, based on this insight. One approach is to extend current workflow systems in order to make them able to deal with exceptions and deviations. Quaglini et al. [2] take such an approach. It is in a way an attempt to relax the control over the course of events without giving up the assumption that this course is to a certain extend pre-determined. A radically different approach is presented in for example Bardram [4]. Clinicians are provided with information about what is going on in their work environment. This awareness enables them to decide on further actions and as a result, determine the course of events. In 2008 we started a nationally funded research project that aims at exploring this second approach towards clinical process

support. COSTT (Co-Operation Support Through Transparency) is a four-year project funded by the Norwegian research council, and has an overall budget of approximately 3.3 million Euros. The main research question in this project is finding out what exactly it is that clinicians have to be aware of and how this information should be presented to them. In this paper we will argue that this question should be answered by looking at the main challenges clinicians face in their everyday work. And as we will try to show, these challenges are not so much related to executing plans or following procedures, but to coping with unforeseen events. Clinicians have developed different ways to cope with these unforeseen events. IT-support should be aimed at supporting these coping strategies. In the next section we will briefly characterize clinical work, focusing on its interruptive nature. In section 3 we will present and discuss three major strategies for coping with unforeseen events that were observed in field work conducted within the COSTT project. In section 4 we will propose some ways in which these empirical findings inform the design of awareness creating applications.

2. THE CHARACTER OF CLINICAL WORK In several studies Coiera and his colleagues have shown that clinical work is highly interruptive ([5],[6]). In a high stress environment such as the ICU department, they reported that doctors and nurses spend up to 80% of their time on communicating, of which 30% was considered as interruptive communication [5]. Chisholm et al. studied emergency department physicians and showed that per 180-min observation, there were a mean of 30.9 ± 9.7 interruptions [7]. Ren et al. [3] describe a study of the operating room environment in which they show that there are many coordination breakdowns in that environment due to both internal and externals interruptions. Internal interruptions arise from events within the clinical process, such as: a deteriorating health condition of a patient, a surgeon being called away to an emergency case or a piece of medical equipment that needs to be used for another patient. External interruptions arise from events occurring outside the clinical process, such as an emergency patient coming to the hospital. These studies show that clinical work, especially in emergency environments such as the ICU and the operation theatre, is highly interruption driven. The reason is that these environments are highly vulnerable to all kinds of unforeseen events that have to be managed. So, the high incidence of interruptions is a symptom of

the contingent character of the work context. People working in such an environment have developed different strategies to handle and control these interruptions. It could very well be that it is the efficacy of these strategies that makes them into proficient workers in these environments. Ren et al. [3] present three coping mechanisms for handling and controlling the interruptions arising from unforeseen events. First of all, clinicians will involve in constant communication in order to stay informed about changes in their work environment. In the case of the occurrence of some unforeseen event, they can collaborate with others to solve the new situation, embarking on what Ren et al. call joint problem solving. Finally, in some cases a new work situation can require people to step in for others; that is some kind of role switching is required. Although we are of the opinion that Ren et al. point in the right direction for looking at possibilities of IT-support, we consider their coping mechanisms to be too much at an implementation level to be really informative for design. Their mechanisms are example strategies that clinicians apply in dealing with the occurrence of unforeseen events. Other strategies or mechanisms are applied in other environments. The approach we will propose in this paper takes the challenges clinicians face in their daily work as a starting point. Health care organizations have designed and implemented formal strategies to cope with these challenges. However, unforeseen events put a strain on these formalized strategies and often cause breakdowns. In these situations health personnel must improvise and develop their local coping strategies to ‘get work back on track’. We will argue that it is exactly these types of situations that are important sources for informing the design of IT-support. In the next three sections we will illustrate this approach by giving some examples from a field study conducted within the COSTT project.

3. METHODS AND MATERIAL The approach in COSTT is based on a philosophy and a desire to work closely with future users. We draw on a number of research methods. However, in the initial phase of the project we mainly use an ethnographic approach, where our aim is to identify problems and concerns which a system has to accommodate to if it is to effectively support work.

3.1 Participant observation The paper is based on participant observations at the surgical ward in a Norwegian University hospital, in particular focusing on the work in and around the operation theatres (approx. 40 hours). The observations include a number of conversations with health personnel. Observations were documented through field notes. Categories of challenges in surgical work and coping strategies were coded and discussed among the authors. In addition, semistructured interviews with a range of actors serve as background material for our understanding of the surgical domain.

3.2 Case The surgical department studied contains eight operation theatres for planned surgery, covering gastrological, urological, vascular, endocrine, and plastic surgery. Surgery is performed between 7.30 am and 3.30 p.m. Acute surgery is performed 24 hours a day. In this paper we focus only on experiences with planned surgery.

Surgical work is a highly collaborative activity, and actors are dependant on each other in order to perform their work in an appropriate way. To facilitate smooth coordination, the hospital has a formal arrangement for coordination, via an operating nurse working full time as a coordinator for planned surgery. Her sole task is to coordinate actors and information, and act as a communicator between the different actors. She works in an office in the middle of the ward, and has access to a wide range of information systems. The coordination office may be seen as the heart of the ward and a ‘bridge’ to the surroundings [8]. A much encountered problem at in-wards in hospitals has been a lack of computers and work stations. In the surgical ward, computers and two screens are placed in each operation theatre, so nurses have no problem getting access to a computer when working in the theatres. The hospital uses a computer system for planning and monitoring surgical activity, called the Operation Planner (Op Plan). At present, however, documentations of operations are still handwritten on paper forms.

4. CHALLENGES AND COPING STRATEGIES Based on our empirical work we discuss how three challenges in clinical work are dealt with: Information gathering, task allocation and resource sharing. They were frequently observed during our fieldwork, and they were given prominence by health personnel in interviews. Although not the only ones, they are among the most important challenges faced by health personnel working in the peri-operative domain we studied. They are recognized by hospital management and so there exist formalized strategies to cope with them. In the following three sub-sections we will present these challenges and give an example of a formal strategy applied to cope with it in our domain of study. After that we describe a situation in which the formal strategy broke down and the health personnel had to improvise in order to cope with it.

4.1 Information gathering One of the greatest challenges in clinical work today is for personnel to be adequately informed about what is going on in their environment. This entails both a need to be informed and to inform. There exist a myriad of formalized systems, routines, regulations etc. in hospitals to ensure that information exchange is taken care of in a proper way. An example of such a formalized system is the operation plan for a given day. The plan states that patient X will undergo an operation, starting at 8 am. Both the operation nurse and the anesthesia nurse use this system to be informed about e.g. name of patient, date of birth and type of procedure. They subsequently wait in the hallway, outside the coordinator’s office to meet the patient. This works fine if the first patient arrives according to plan at the operation department. However, in the observed case the patient still had not arrived ten minutes after schedule. So, the plan and the formal system broke down. There was also no other formal system that the nurses could turn to in order to find out where the patient was. That would have been the case if for example the

exact location of a patient was registered somewhere, possibly in an automatic way by using location technology. In the case at hand, the operation nurse had to fall back on an informal strategy and decided to ask the coordinator to find out why the patient was delayed. So, this unforeseen event of delay generated interruptions for the operation nurse, the anesthesia nurse and the coordinator.

4.2 Task allocation Another challenge in clinical work is task allocation to health personnel. This challenge becomes more acute as an increasingly specialization is taking place in health care. For example, a surgical procedure may come to a stop due to the unavailability of a particular surgeon with the required skills. The challenge of allocating appropriate personnel to the right tasks is of course more critical the scarcer the resource (the personnel) is. E.g. senior anesthetists were a scarce resource in the hospital we studied. Also the time of day will affect how serious the challenge is. Late shifts might be more difficult to cope with task allocation than morning shifts, due to fewer personnel on duty. There are several formal systems applied to cope with this challenge. An obvious one is the personnel planning system that allocates personnel to shifts and operations. Another system used is the so-called be duty or be on call system. Personnel are explicitly allocated the task of being available in the case of unforeseen circumstances. During our fieldwork we observed a case in which a patient undergoing surgery proved to have an uncommon, bony outgrowth in the stomach. The young, not very experienced surgeon doing the operation needed the help of an experienced surgeon in handling this. An experienced, senior surgeon was called into the operation room and assisted with the operation. This (re-)allocation of the experienced surgeon happened outside the formal systems and was handled in an improvised, ad hoc matter. There also was no proper strategy for re-allocating the tasks that the experienced surgeon actually had to perform. So, the breakdown of the formal system of task allocation potentially led to a series of delays and/or cancellations.

4.3 Resource sharing Resources, e.g. advanced and expensive equipment, are often scarce in hospitals and necessitate sharing between health personnel. The sharing in turn calls for some kind of system for booking, and an overview of whether equipment is free and available. Coordination of this resource sharing is a third main challenge encountered by health personnel in the peri-operative domain. In the hospital studied formal systems (of course) existed for all major laboratory examinations and equipment, like ultrasound, MRI and x-ray. However, for smaller and more locally belonging equipment, like endoscopic equipment, no formal booking system existed. If a surgeon planned to perform, say, an endoscopic examination he had to note that in the operation planning information system OpPlan. The operation nurse would then be informed when preparing the operation that endoscopic equipment would have to be prepared and available. We observed, however, a case in which the surgeon decided to do an endoscopic examination when talking to and examining the patient at the start of the operation. This caused the formal system to break down. The operation nurse had to fall back to an ad hoc

strategy of looking in the hallway where endoscopic equipment is kept when not in use. Finding out that it was not there, she had to check the other operation rooms to see if there was any unused equipment there.

5. REQUIREMENTS FOR IT SUPPORT The three examples of breakdowns of the formal system in the face of unforeseen events indicate directions for IT-support. It is important to stress that the examples of unforeseen events are not examples of extremely rare situations. They are actually quite common in the highly dynamic environment of the peri-operative domain. In this section we will briefly discuss three types of ITsupport that follow from the observation of breakdowns presented in the previous section. Visualize the patient’s trajectory – In the example presented in section 4.1, it would have been of great help if the operation nurse and the anesthesia nurse would have been able to see where the patient was, not only in the sense at which location but also in the sense at which phase in the preparation to be operated. They could then have seen if the patient was on his/her way down to the operation department, or if he/she was still at the in-ward. One of the aims of the COSTT project is to visualize the patient trajectory. Visualize the personnel’s trajectory – Personnel planning systems give insight into the whereabouts and availability of health personnel. However, as we have seen, ad hoc re-allocations cause the formal systems to break down. Keeping a real-time update overview of whom is allocated to which task, could help in avoiding these breakdowns to occur and avoiding or timely resolving delays. An example of such a system is described in Bardram et al [4], where the people actually in an operating room are displayed on screens that can be accessed from different locations. Visualize the equipment’s trajectory – A booking system for crucial equipment or resources such as rooms is an effective formal system enabling sharing these resources. For equipment that must be applied in a flexible way, such as the endoscopic equipment discussed in the example, such a formal booking system is too rigid. A more appropriate system would show location and status (in use, idle, not-prepared, …) of the piece of equipment. Based on this the OR team could more accurately decide how to fit in an ad hoc examination in the operation schedule.

6. Conclusion The occurrence of unforeseen events is a main characteristic of clinical work. Unforeseen events will most often be perceived by health personnel as interruptions. IT-support should not aim at reducing the number of unforeseen events by imposing plans and guidelines on clinical work, but on supporting the management of interruptions generated by these unforeseen events. We have argued that studying the breakdowns of formal systems in place to cope with the main challenges faced by health personnel is a major source for informing the design of systems for work support. By means of illustrating our point we discussed three examples of such breakdown situations and indicated how ITsupport could have helped in coping with them. Our approach can be contrasted with the one proposed in Ren et al. [3]. They focus on specific strategies and derive requirements from them. The problem with this approach is that there is no

insight into where these strategies are successful and where they break down. Only in the latter case there is the need for improvement.

7. ACKNOWLEDGMENTS This research is funded by the research council of Norway (NFR). The authors express their gratitude to the staff at St.Olavs hospital, the Norwegian university hospital, with whom the workplace studies were conducted and to colleagues at the Department of Computer and Information Science and Norwegian Centre for Electronic Patient Record Research.

8. REFERENCES

Recommendations. Journal of Management Information Systems, 2008. 25(1): p. 105–130 [4] Bardram, J.E., T.R. Hansen, and M. Soegaard. 2006. AwareMedia - A Shared Interactive Display Supporting Social, Temporal, and Spatial Awareness in Surgery, in CSCW'06 Banff, Alberta, Canada: ACM. [5] Coiera, E.W., R.A. Jayasuriya, J. Hardy, A. Bannan, M.E. Thorpe. 2002. Communication loads on clinical staff in the emergency department, Med. J. Aust. 176 (9) 415—418. [6] Alvarez, G. and E. Coiera. 2005. Interruptive communication patterns in the intensive care unit ward round, Int J Med Inform 74 (10), pp. 791–796.

[1] Bardram, J.E., 1997. Plans as situated action: an activity theory approach to workflow systems. In Proceedings of the fifth European Conference on Computer-Supported Cooperative Work Lancaster, UK, pp. 17 – 32, ACM Press, New York.

[7] Chisholm, C.D., E.K. Collison, D.R. Nelson, W.H. Cordell. 2000. Emergency department workplace interruptions: are emergency physicians ‘‘interrupt-driven’’ and ‘‘multitasking’’? Acad. Emerg. Med. 7 (11) (2000) 1239— 1243.

[2] S. Quaglini, M. Stefanelli, G. Lanzola et al.. 2001. Flexible guideline-based patient careflow systems. Artif. Intell. Med. 22 1, pp. 65–80.

[8] Hazlehurst, B., C. K. McMullen, and P. N. Gorman. 2007. Distributed cognition in the heart room: How situation awareness arises from coordinated communications during cardiac surgery, Journal of Biomedical Informatics, vol. 40, pp. 539-551.

[3] Ren, Y., S. Kiesler, and S.R. Fussell. 2008. Multiple Group Coordination in Complex and Dynamic Task Environments: Interruptions, Coping Mechanisms, and Technology