Understanding resilient clinical practice in Emergency Department ecosystems. Jeffrey Braithwaite, PhD Robyn Clay-Williams, PhD

Transcription

1 Understanding resilient clinical practice in Emergency Department ecosystems Australian Institute of Health Innovation Jeffrey Braithwaite, PhD Robyn Clay-Williams, PhD Presentation to the Resilient Healthcare Net Conference Middlefart, University of Southern Denmark 12 August 2014

2 Australian Institute of Health Innovation s mission Our mission is to enhance local, institutional and international health system decisionmaking through evidence; and use systems sciences and translational approaches to provide innovative, evidence-based solutions to specified health care delivery problems.

3 Australian Institute of Health Innovation Professor Jeffrey Braithwaite Foundation Director, AIHI; Director, Centre for Clinical Governance Research Professor Enrico Coiera Director, Centre for Health Informatics, AIHI, UNSW Professor Ken Hillman Director, Simpson Centre for Health Services Research, AIHI, UNSW Professor Johanna Westbrook Director, Centre for Health Systems and Safety Research, AIHI, UNSW

4 Resilient health care is taking root Two scholarly compendiums: but Hollnagel, E., Braithwaite, J. and Wears, R. (eds) (2013) Resilient health care, London, Ashgate. Wears, R., Hollnagel, E., Braithwaite, J. (eds) (In press) The resilience of everyday clinical work, London, Ashgate. There is much further to go to add to our understanding of when things go right We need to appreciate the habituations and routines that characterise clinical work

5 How? Complement theories to account for clinical coalface processes with a set of effective empiricisations Capture and report on salient examples of how, when nothing goes wrong, things are done

6 Why Emergency settings? Emergency Departments (EDs) are fascinating habitats which are: time-critical, richly interactive idiosyncratically hierarchical and heterarchical intermittently time-pressured, and complex adaptive systems [CASs] EDs mostly get things right, despite temporal demands resource constraints expansive casemix and workplace complexity.

7 However most people have this mental model

8 But healthcare really looks like this 8

9 ED Study #1 flow structures Nugus et al emergency clinicians create a carousel providing the greatest good for the greatest number of patients ED clinicians are rationing time to provide beds to meet the needs of future patients Work is therefore inherently clinicalorganisational Time and motion are chief characteristics Therefore flow/trajectories of patients is what is really managed by ED [Nugus et al. Int Emerg Nurs, 2014]

10 The carousel model of the ED.

11 ED Study #2 flow pressures Junior nurse perspective on role of Clinical Initiatives Nurse (CIN): To save time; they speed things up, especially in sub-acute. A senior nurse: We take every chance we can get to free up a bed. For each patient as soon as they come in you ve got to think of the best way to get them out.

12 ED Study #3 A riot of a study The Stanley Cup Riots, 2011, Vancouver, Canada 500 people into city every 90 seconds by SkyTrain alone Big surge of patients to ED Key take-outs: capacities for Speedup, Slowdown, resource flex, margin for manoeuvre [Hunte, In: The resilience of everyday clinical work, 2014]

13 ED Study #4 tribal characteristics Micro-structural dimensions of interactive behaviours to reveal tribal characteristics Social network analysis to illuminate the social-professional structures An anaesthetist now working in ED: I bag [criticise] anaesthetists even though I m an anaesthetist.

14 ED Study #4 exposing tribes Admin 12 Admin 1 Sr nurse 22 Admin 11 Sr dr 3 Admin 8 Admin 9 Allied health 3 Jr RN 9 Sr nurse 13 Admin 5 Jr dr 2 Sr RN 13 Sr RN 14 Sr RN 6 Sr nurse 18 Admin 4 Sr nurse 1 Sr RN 1 Sr nurse 9 Jr dr 10 Jr dr 21 Sr nurse 11 Admin 3 Jr dr 7 Sr nurse 21 Sr dr 7 Jr dr 15 Sr nurse 6 Admin 2 Jr dr 20 Sr dr 5 Jr RN 4 Jr dr 8 Sr nurse 17 Ward asst 1 Sr nurse 2 Admin 10 Admin 7 Jr dr 5 Sr dr 4 Sr dr 1 EN 4 Sr nurse 4 Sr RN 5 Admin 6 Jr dr 17 Sr nurse 8 Jr dr 12 Sr RN 4 Sr nurse 10 Ward asst 2 Jr dr 9 Jr dr 23 Sr nurse 5 Jr dr 1 Sr dr 2 Sr RN 7 Sr nurse 14 Sr nurse 12 Allied health 4 Jr dr 4 Sr nurse 3 Jr RN 10 Sr RN 8 Sr dr 6 Jr RN 8 Sr nurse 7 Jr dr 13 Jr RN 11 Jr RN 3 Sr RN 2 Jr dr 16 Sr nurse 15 Sr RN 10 Jr dr 29 Jr dr 6 Jr dr 11 Jr RN 1 Sr nurse 16 Allied health 2 Jr RN 6 Sr RN 3 Jr dr 22 EN 5 EN 2 Jr dr 18 Jr dr 24 Jr RN 7 Jr RN 2 Jr dr 25 EN 1 Sr RN 9 EN 3 Allied health 1 Jr RN 5 EN 6 Sr RN 11 Sr nurse 20 Jr dr 14 Jr dr 19 Jr RN 12 Sr RN 12 Jr dr 3 Sr nurse 19 Jr dr 27 Jr dr 30 Jr dr 26 Jr dr 28 Problem solving networks in an ED Nurses Doctors Allied health Admin and support [Creswick, Westbrook and Braithwaite, BMC HSR, 2009] 14

15 ED Study #4 exposing tribes Admin 1 Admin 12 Ward asst 1 Sr RN 14 Admin 8 Allied health 3 Sr RN 13 Admin 7 Sr nurse 22 Jr dr 26 Admin 3 Jr dr 30 Sr nurse 1 Admin 4 Jr dr 28 Allied health 4 Admin 9 Allied health 2 Sr dr 3 Sr nurse 13 Admin 11 Sr nurse 11 Admin 5 Jr dr 27 Sr nurse 9 Jr dr 2 Sr RN 8 Admin 10 EN 6 Sr nurse 21 Sr dr 4 Jr dr 25 Sr nurse 2 Sr dr 6 Sr nurse 12 Sr nurse 17 Jr dr 9 Jr dr 20 Jr dr 6 Sr dr 2 Jr RN 4 Admin 2 Ward asst 2 Sr nurse 3 Sr nurse 4 Admin 6 Jr dr 10 Sr dr 1 Sr nurse 10 Sr RN 4 Jr dr 29 Jr dr 8 Sr nurse 6 Sr dr 7 EN 1 Sr RN 1 Sr RN 7 Sr RN 6 Jr dr 3 Sr RN 11 Jr RN 11 Allied health 1 Sr RN 9 EN 2 Sr nurse 5 Jr dr 19 Jr dr 24 Jr RN 10 Sr nurse 8 Sr nurse 20 Sr dr 5 Jr RN 2 Jr dr 11 Sr nurse 14 Jr dr 12 Jr RN 3 Sr RN 2 Jr RN 6 Jr dr 17 Jr dr 21 Jr RN 8 EN 5 Sr nurse 7 Jr dr 22 Jr dr 1 Sr RN 10 Jr dr 23 Sr RN 5 Sr nurse 19 Jr dr 16 Jr dr 15 Jr RN 1 EN 4 Jr dr 18 Sr nurse 15 Jr dr 7 Jr RN 9 Sr nurse 16 Jr dr 4 Jr dr 13 Jr RN 5 Jr dr 5 Jr RN 7 Jr dr 14 Sr nurse 18 EN 3 Sr RN 3 Jr RN 12 Sr RN 12 Medication adviceseeking networks in an ED Nurses Doctors Allied health Admin and support [Creswick, Westbrook and Braithwaite, BMC HSR, 2009] 15

16 ED Study #4 exposing tribes Jr dr 20 Jr dr 27 Jr dr 22 Jr dr 25 Jr dr 1 Jr dr 26 Jr dr 10 Jr dr 5 Jr dr 16 Jr dr 18 Jr dr 28 Sr dr 3 Jr dr 15 Jr dr 3 Jr dr 7 Jr dr 17 Jr dr 14 Jr dr 13 Jr dr 8 Jr dr 19 Jr dr 6 Jr dr 4 Allied health 2 Admin 1 Allied health 1 Sr RN 13 Jr RN 2 Jr dr 2 Admin 3 Sr dr 1 Sr dr 4 Sr RN 14 Sr dr 7 Sr nurse 1 Sr dr 2 Sr dr 5 Sr dr 6 Sr nurse 11 Sr nurse 22 Sr nurse 4 Allied health 3 Sr nurse 5 Admin 5 Admin 2 Admin 4 Admin 9 EN 5 Sr nurse 12 Sr RN 11 Ward asst 2 Sr RN 5 Admin 12 Admin 11 Sr nurse 3 Admin 10 Admin 8 Allied health 4 Sr nurse 10 Sr RN 4 Sr nurse 6 EN 6 Jr RN 1 Sr nurse 15 Jr dr 9 Admin 6 Sr nurse 9 Sr nurse 20 Jr dr 11 EN 4 Jr RN 3 Sr nurse 2 Jr dr 24 Jr RN 10 Jr RN 9 Sr RN 7 Jr RN 8 Sr nurse 13 Sr nurse 8 Sr nurse 14 Sr nurse 17 EN 1 Sr RN 2 Jr dr 23 Jr RN 7 Jr RN 6 Jr RN 11 Sr nurse 18 Sr nurse 21 Sr RN 3 Sr nurse 16 Sr RN 8 Sr RN 12 Sr RN 6 EN 2 Jr dr 21 Sr nurse 7 Sr nurse 19 Jr RN 4 Sr RN 1 Sr RN 10 EN 3 Jr dr 12 Sr RN 9 Jr RN 12 Jr RN 5 Admin 7 Ward asst 1 Socialising networks in an ED Nurses Doctors Allied health Admin and support Jr dr 29 Jr dr 30 [Creswick, Westbrook and Braithwaite, BMC HSR, 2009] 16

17 ED Study #5 external connections ED clinicians work in environment of flexible dynamic interconnectedness Negotiate with other departments and package the patient for a category [Aged care? Cardiology?] Specialist ED physician: We were trying to sell the patient for review. It s easier to ask them to review. Admission comes later. Registrar: Are you a medical registrar? [No] Oh well, I won t try and sell you a patient. [Nugus, Bridges and Braithwaite, BMJ, 2009]

18 ED Study #5 external connections Cardiology registrar: We re overloaded. I mean, I m a human being We re just so short of time what are you going to do?... You try not to come down unless you re convinced there s a good chance it s one of ours. ED registrar: A frustration is that we have to do the work of the inpatient team. We do the workup. It stresses us out and we turn that stress onto the nurses. We re Cinderella. We do the dirty work but don t get invited to the party.

19 ED Study #6 technology use Supportive artefacts and technologies, e.g.: computers, pens-and-paper, stethoscopes, medical records, sticky notes, bed allocation boards, referral and discharge letters.

20 ED Study #7 secret second handover Ambulance paramedics determine when a secret second handover is needed with cubicle nurses Eschews formality in favour of informality An adjustment strategy Constitutes a dynamic trade-off between efficiency and thoroughness [Sujan, Spurgeon and Cooke, In: The resilience of everyday clinical work, 2014]

21 ED overall a resilient ecosystem ED clinicians demonstrate: Handling of complexity Discursive competence Communicative flexibility Working organisational-clinical interfaces Sacrificing lower for higher order goals Future-orientation in their work Nuanced understanding of interdepartmental working

22 The rich tapestry of EDs. Other ED-focused work in The resilience of everyday clinical work is: Nakijima on blood transfusions in ED Stephens, Woods and Patterson on patient boarding and capacity for manoeuvre [CfM] in EDs

23 Lessons Lots of knowledge operates to create resilience in EDs moment-to-moment, dayto-day, week-to-week Resilience is continually created in such circumstances People exercise their capacity for manoeuvre amongst the ebbs and flows of patients, tribal relationships, internal and external connections and varied modes of operating

24 Finally We have our own ideas on the next generation of research questions to ask But what s the next set of questions you would ask if you were doing work on the resilience of EDs?

25 Selected References Braithwaite, J., Clay-Williams, R., Nugus, P. and Plumb, J. (2013) Health care as a complex adaptive system. In: Hollnagel, E., Braithwaite, J. and Wears, R. (eds) Resilient health care, London, Ashgate. Creswick, N., Westbrook, J. and Braithwaite, J. (2009) Understanding communication networks in the emergency department. BMC Health Services Research, 9:247 doi: / Hunte, G. (2014). A lesson in resilience: the 2011 Stanley Cup riot. In: Wears, R., Hollnagel, E., Braithwaite, J. The resilience of everyday clinical work, London, Ashgate. Nakijima, K. (2014). Blood transfusion with health information technology in emergency settings from a Safety-II perspective. In: Wears, R., Hollnagel, E., Braithwaite, J. The resilience of everyday clinical work, London, Ashgate. Nugus, P., Bridges, J. and Braithwaite, J. (2009) Selling patients. British Medical Journal, 339:b5201. Nugus, P., Carroll, K., Hewett, D.G., Short, A., Forero, R. and Braithwaite, J. (2010) Integrated care in the emergency department: a complex adaptive systems perspective. Social Science & Medicine, 71 (11):

26 Selected References Nugus, P., Forero, R., McCarthy, S., McDonnell, G., Travaglia, J., Hillman, K. and Braithwaite, J. (2014) The emergency department carousel : an ethnographicallyderived model of the dynamics of patient flow. International Emergency Nursing, 22: 3-9. Nugus, P., Holdgate, A., Fry, M., Forero, R., McCarthy, S. and Braithwaite, J. (2011) Work pressure and patient flow management in the emergency department: findings from an ethnographic study. Academic Emergency Medicine, 18(10): Nugus, P., Sheikh, M. and Braithwaite, J. (2012) Structuring emergency care: policy and organisational behavioural dimensions. In: Dickinson, H. and Mannion, R. (eds) The reform of health care: shaping, adapting and resisting policy developments, London, Palgrave Macmillan, pp Stephens, R., Woods, D. and Patterson E. (2014). Patient boarding in the emergency department as a symptom of complexity-induced risks. In: Wears, R., Hollnagel, E., Braithwaite, J. The resilience of everyday clinical work, London, Ashgate. Sujan, M. A., Spurgeon, P. and Cooke, M.W. (2014). Translating tensions into safe practices through dynamic trade-offs: the secret second handover. In: Wears, R., Hollnagel, E., Braithwaite, J. The resilience of everyday clinical work, London, Ashgate.

27 Contact details Jeffrey Braithwaite, PhD Foundation Director Australian Institute of Health Innovation Director Centre for Clinical Governance Research Professor, Faculty of Medicine University of New South Wales SYDNEY NSW 2052 AUSTRALIA Wiki: Web: