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

22

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. mnasarw1@jhmi.edu

Ayse Gurses, Ph.D. agurses1@jhmi.edu

Anping Xie, PhDaxie1@jhmi.edu