Patient safety in outpatient surgery: the viewpoint of the healthcare providers

The objective of this study is to understand the viewpoint of healthcare providers with regard to patient safety in outpatient surgery settings. Two methods were used to gather data from the healthcare providers: (1) questionnaire with open-ended questions about six predefined stages of the patient care process; (2) survey with closed questions. With the first method, the main quality and safety of care issues concerned communication to patients, coordination of reports and forms, patient and staff time pressures and standards of care. The first two stages of the outpatient surgery process, i.e. patient work-up prior to day of surgery and patient admission and preparation on the day of surgery, yielded many more comments than the other four stages. The results of the structured questionnaire show that, overall, the healthcare providers report high quality of care provided by themselves (98%) and their surgery centre (96%). With regard to patient safety (i.e. cancellations of surgeries, patient safety problems and serious mistakes), there was a clear difference in perceptions reported by the physicians vs. the nurses and other staff. Nurses and other staff were more likely to report patient safety problems than physicians. The combination of qualitative data from the initial questionnaire and the quantitative data from the structured questionnaire provides a rather complete view of the outpatient surgery staff perceptions of quality and safety of care. This research highlights the importance of getting input from the healthcare providers regarding the quality and safety of care rather than relying only on traditional measures about patient outcomes.     

Private and Secure Service Discovery via Progressive and Probabilistic Exposure

The involvement of only the necessary users and service providers for service discovery in pervasive computing environments is challenging. Without prudence, users' and service providers' requests or service information, their identities, and their presence information may be sacrificed. We identify that the problem may be as difficult as a chicken-and-egg problem, in which both users and service providers want the other parties to expose sensitive information first. In this paper, we propose a progressive and probabilistic approach to solve the problem. Users and service providers expose partial information in turn and avoid unnecessary exposure if there is any mismatch. Although 1 or 2 bits of information are exchanged in each message, we prove that the process converges and that the false-positive overhead decreases quickly. Experiments and hypothesis tests show that security properties hold. We implemented the approach and the performance measurements show that the approach runs efficiently on PDAs.     

E-EPR: a workflow-based electronic emergency patient record

Emergency care is, politically and socially, one of the highest priorities in society today. Increasing patient expectations and the advancement of scientific and medical knowledge has had a dramatic effect on the provision of emergency care. Emergency medical services (EMSs) perform pre-hospital and in-hospital emergency care activities, operate 24 h a day/7 days a week and constitute an important link between the community (primary care) and the hospital (secondary and tertiary care). Managing emergency care involves assessing individual needs to create a coordinated plan of care that is consistent with agreed priorities and is designed to bring optimal outcomes using cost-effective care. Emergency care is vital for avoiding death and chronic suffering by the elderly and the homeless, but its overall positive effect on the long-term health and overall well-being of these people can only be improved significantly by applying holistic principles, going beyond basic medical care to offer psychological and social support as far as possible. Thus, creating appropriate emergency care plans requires collaboration and coordination among EMS and social care providers, giving rise to a more holistic approach to emergency care management. In turn, this requires the availability of integrated patient information to authorized individuals of health and social care providers when and where needed. On these grounds, the development of a workflow-based electronic patient record (E-EPR) for emergency care is described which is provided as a service on a cloud. The E-EPR aims at supporting the execution of EMS workflows by providing integrated patient information to EMS process participants and to make this information shareable to health and social care professionals. Due to the heterogeneity of the participating organizations’ information systems, the E-EPR is built on top of an Integrating the Healthcare Enterprise (IHE)-based collaborative network consisting of EMS agencies and health and social care providers who share patient documents using IHE-based profiles. An experimental implementation of the E-EPR is also described.     

Barriers to implementing wrong site surgery guidelines: a cognitive work analysis

In 1998, the Joint Commission on Accreditation of Healthcare Organizations identified important contributors to surgical site misidentification in the operating room (OR), including communication breakdown between surgical team members and the patient, availability of pertinent information, failure of OR policies and procedures, incomplete patient assessment, and distraction. Prior to this, the American Academy of Orthopedic Surgeons (AAOS) among others, developed guidelines intended to reduce the likelihood of misidentification in surgical procedures. We hypothesized these guidelines were inconsistently implemented because of the failure to account for the dynamic complex OR environment. Over 40 h of direct observation of the entire care process (from initial consultation through postoperative care) were conducted at two hospitals. Our analysis identified critical process elements that impact the outpatient surgical process of identification. Time pressure, crosschecking, uncooperative communication culture, complexity in the work process, attention/distraction, and documentation concerns make guidelines that rely on verification of the site complicated and vulnerable to error. Suggestions for improvements in processes are made.     

Embedding robotic surgery into routine practice and impacts on communication and decision making: a review of the experience of surgical teams

While an increasing number of healthcare providers are purchasing surgical robots because of anticipated improvements in patient outcomes, their implementation into practice is highly variable. In robotic surgery, the surgeon is physically separated from the patient and the rest of the team with the potential to impact communication and decision making in the operating theatre and subsequently patient safety. Drawing on the approach of realist evaluation, in this article we review reports of the experience of surgical teams that have introduced robotic surgery to identify how and in what contexts robotic surgery is successfully integrated into practice and how and in what contexts it affects communication and decision making. Our analysis indicates that, while robotic surgery might bring about a number of benefits, it also creates new challenges. Robotic surgery is associated with increased operation duration, which has implications for patient safety, but strategies to reduce it can be effective with appropriate support from hospital administration and nursing management. The separation of the surgeon from the team can compromise communication but may be overcome through use of standardised communication. While surgeon situation awareness may be affected by the separation, the ergonomic benefits of robotic surgery may reduce stress and tiredness and enhance surgeon decision making. Our review adds to the existing literature by revealing strategies to support the introduction of robotic surgery and contextual factors that need to be in place for these to be effective.     

A consensus support model based on linguistic information for the initial-self assessment of the EFQM in health care organizations

The improvement of the quality of the services is one of the primary sources of competitive advantage in health care organizations. As customers typically search for higher quality of care when choosing treatments, health plans and providers, the health care organizations strive to improve the quality of care and patient safety and satisfaction, as primary goals, with the resources that are available. To do so, the European Foundation for Quality Management (EFQM) Excellence Model for self-assessment has been used by the health care organizations to improve their services and their competitiveness in the global market. However, when the health care organizations address self-assessment processes for the first time, the initial effort needed presents many difficulties. The aim of this paper is to offer a consensus support model based on linguistic information to conduct the self-assessment of the EFQM Excellence Model when questionnaires are used. It is based on the use of linguistic information to provide the individuals’ opinions, which facilitates the individual responses, and on the use of fuzzy majority, represented by means of a linguistic quantifier, to compute the measures guiding the consensus reaching process.     

Cyber patients surfing the medical web: Computer-mediated medical knowledge and perceived benefits

Information and communication technologies have introduced new and impressive tools for information sharing and building computer-mediated knowledge repositories in a global context. Clinicians and researchers pay particular attention to technology as a promising tool to empower patients through self-health care management skills and to improve health care communication with providers. This represents a significant step in modern medicine of computer-integrated patient self-health care. This paper aims to examine perceived informational and decisional benefits of computer-mediated health and medical information, more specifically of cancer web-sites, and presents the results of two separate statistical models of perceived benefits. Multivariate hierarchical regression analyses showed that the frequency and time spent visiting medical web-sites are significant predictors of perceived benefits of computer-mediated knowledge. The results also indicated that computer-mediated medical information empowers health consumers to make informed decisions for their health care. The discussion section of the paper contextualizes the findings within the current sociomedical trends of self-health care and partnership with health providers. It is important to understand the perceived benefits of using computer-mediated medical knowledge, so that information and communication technologies can be targeted to educate patients to make informed decisions and to develop patient self-health-care management competencies.     

Following the trail: understanding information flow in the emergency department

A hospital emergency department (ED) is a complex cognitive work system. ED providers routinely create, process and share various kinds of information in their work. They may constantly transform information using technological artifacts such as an electronic patient information system. The functionality in the technology, however, limits their tasks and activities. So, they create their own artifacts (such as handwritten notes on a post-it note), to share and process information. The goal of the paper is to illustrate how health providers in EDs create, process, transform and share information to achieve work goals. We present the information trail model in the ED to illustrate various facets of information creation activity and generate insights for health information technology design.     

Macroergonomics and patient safety: The impact of levels on theory, measurement, analysis and intervention in patient safety research

The study and practice of patient safety has seen a surge over the last 10 years. New resident training and staffing policies, health information technologies, error reporting systems, team models of care, training methods, patient involvement, information handoff strategies, just cultures, and many other interventions have been mandated or attempted to improve the safety of patient care. While some of these interventions focus on individual providers and others focus on organization-level changes, little, if any, patient safety research has purposefully sought to understand how variables at different levels, such as the provider level or organization level, interact to impact patient safety outcomes such as errors, adverse drug events, or patient harm. Looking at relationships across levels is important because adverse events might be related to variables at different levels; consider that adverse events may be nested within patients, patients nested within nurses and physicians, nurses and physicians nested within shifts, shifts nested within hospital units, and so forth. Because these nested levels exist, they may exert as yet untested influence on the levels below. In this paper the impact of levels on theory, measurement, analysis and intervention in patient safety research is discussed.     

Patient-borne memory device facilitates "point of care" data access.

Although electronic medical records and a central database have made accurate and consistent patient medical information more readily available than with the traditional patient chart, there are many locations in healthcare facilities where terminals for accessing patient data are not available. As patient care becomes decentralized and more patients require anesthesia outside of the operating suites, routing a network-based system to all these locations can be expensive and time consuming. We designed a system whereby essential patient data of interest to anesthesiologists is stored on an electronic memory device the size of a watch battery attached to the patient's wristband. Accessing and editing the data is done via a hand-held computer. This system provides secure patient data storage and management at the "point of care." At the conclusion of the patient's anesthesia-related care, the data is downloaded to a relational database for use in outcome analysis, billing, and quality assurance. After collecting preoperative evaluations, intraoperative data, and postoperative data on 560 patients anesthetized for surgery or other procedures, we find this system to be a reliable, low-cost, medical information management system, with possible application to other medical specialties.     

A macro-ergonomic work system analysis of the diagnostic testing process in an outpatient health care facility for process improvement and patient safety

The diagnosis of illness is important for quality patient care and patient safety and is greatly aided by diagnostic testing. For diagnostic tests, such as pathology and radiology, to positively impact patient care, the tests must be processed and the physician and patient must be notified of the results in a timely fashion. There are many steps in the diagnostic testing process, from ordering to result dissemination, where the process can break down and therefore delay patient care and reduce patient safety. This study was carried out to examine the diagnostic testing process (i.e. from ordering to result notification) and used a macro-ergonomic work system analysis to uncover system design flaws that contributed to delayed physician and patient notification of results. The study was carried out in a large urban outpatient health-care facility made up of 30 outpatient clinics. Results indicated a number of variances that contributed to delays, the majority of which occurred across the boundaries of different systems and were related to poor or absent feedback structures. Recommendations for improvements are discussed.     

Impact on the management and delivery of primary health care by a computer-based information system.

Timely and accurate information forms the basis for management to plan and for care providers to take appropriate action. We report from a developing country a research project aimed to strengthen the information infrastructure with a computer at a Primary Health Centre. The software (MCHS) was designed to assist the care providers in the information management for the Maternal and Child Health (MCH) programme activities. In Phase I, a baseline survey was conducted to identify the needs and target groups. In Phase II, the MCHS was integrated into routine delivery of MCH to monitor the target population and help in evaluation. The research project's impact is reflected in enhanced utilization of services and quality in care, as seen by reduction of dropouts from the immunization program. In economic terms, we see that the costs for a fully immunised child are reduced with reduction of dropouts; thus, the computer system contributes to quality assurance and cost effectiveness in delivery of care.     

Patient source of learning about health technologies and ratings of trust in technologies used in their care

In order to design effective health technologies and systems, it is important to understand how patients learn and make decisions about health technologies used in their care. The objective of this study was to examine patients' source of learning about technologies used in their care and how the source related to their trust in the technology was used. Individual face-to-face and telephone interviews were conducted with 24 patients. Altogether, 13 unique sources of information about technology were identified and three major themes emerged: outside of the work system vs. inside the work system; when the health information was provided; the medium used. Patients used multiple sources outside of the healthcare work system to learn about technologies that will be used in their care. Results showed a relationship between learning about technologies from web sources and trust in technologies but no relationship between learning about technologies from healthcare providers and trust in technologies. STATEMENT OF RELEVANCE: The value of considering human attitudes about elements in health systems has been illustrated. This research shows a relationship between patient attitudes about medical technologies used in their care and healthcare work system design. Results show that patient attitudes are formed about technologies used in their care by sources within and outside of the sociotechnical work system.     

Visual computing for medical diagnosis and treatment

Diagnostic algorithms and efficient visualization techniques are of major importance for preoperative decisions, intra-operative imaging and image-guided surgery. Complex diagnostic decisions are characterized by a high information flow and fast decisions, requiring efficient and intuitive presentation of complex medical data and precision in the visualization. For intra-operative medical treatment, the pre-operative visualization results of the diagnostic systems have to be transferred to the patient on the operation room table. Via augmented reality, additional information of the hidden regions can be displayed virtually. This state-of-the-art report summarizes visual computing algorithms for medical diagnosis and treatment. After starting with direct volume rendering and tagged volume rendering as general techniques for visualizing anatomical structures, we go into more detail by focusing on the visualization of tissue and vessel structures. Afterwards, algorithms and techniques that are used for medical treatment in the context of image-guided surgery, intra-operative imaging and augmented reality are discussed and reviewed.     

Trust in medical technology by patients and healthcare providers in obstetric work systems

Multiple types of users (i.e. patients and care providers) have experiences with the same technologies in healthcare environments and may have different processes for developing trust in those technologies. The objective of this study was to assess how patients and care providers make decisions about the trustworthiness of mutually used medical technology in an obstetric work system. Using a grounded theory methodology, we conducted semi-structured interviews with 25 patients who had recently given birth and 12 obstetric healthcare providers to examine the decision-making process for developing trust in technologies used in an obstetric work system. We expected the two user groups to have similar criteria for developing trust in the technologies, though we found patients and physicians differed in processes for developing trust. Trust in care providers, the technologies' characteristics and how care providers used technology were all related to trust in medical technology for the patient participant group. Trustworthiness of the system and trust in self were related to trust in medical technology for the physician participant group. Our findings show that users with different perspectives of the system have different criteria for developing trust in medical technologies.     

HL7 looks beyond the hospital walls

HL7 is trying to build a bridge linking more than just providers and payers. Through electronic data interchange, the standards group hopes to better link physicians' practice management systems with their affiliated hospitals' information system, creating a crossfeed of information that could ultimately have profound effects on the quality of patient care.     

Patient flow modelling and performance analysis of healthcare delivery processes in hospitals: A review and reflections

Analysis of hospital processes is essential for development of improved methods, policies and decision tools for overall performance improvement of the hospital system. Amidst the current scenario of continuously increasing healthcare costs and scarcity of resources, optimal utilization of resources without hampering the quality of care has gained importance in any country. Modelling, analysis and management of patient flows, in this context, plays a key role in performance analysis and improvement of hospital processes as appropriate modelling of patient flows may help healthcare managers make decisions related to capacity planning, resource allocation and scheduling, appointment scheduling and for making necessary changes in the process of care. The concept of patient flow and its modelling has gained much attention in healthcare management literature over past few decades. In this paper, the existing approaches pertaining to modelling of patient flows in hospital systems have been classified and critically appraised focussing on the recent advancements in order to identify future research avenues. A generic framework for patient flow modelling and performance analysis of hospital systems that may serve as a guide for the practitioners dealing with similar kinds of problems to improve healthcare delivery has also been provided.