Information Needs and the Use of Documentation to Support Collaborative Decision-Making: Implications for the Reduction of Central Line-Associated Blood Stream Infections.

It is clear that interdisciplinary communication and collaboration have the potential to mitigate healthcare-associated harm, yet there is limited research on how communication through documentation in the patient record can support collaborative decision making. Understanding what information is needed to support collaborative decision making is necessary to design electronic health information systems that facilitate effective communication and, ultimately, safe care. To explore this issue, we focused on information needs related to central venous catheter management and the prevention of central line-associated blood stream infections. Semistructured interviews were conducted with nurses working in an intensive care unit. Interview transcripts were analyzed using inductive thematic analysis. Three themes were identified: (1) challenges managing documentation in multiple places in the absence of formal documentation processes for central venous catheter management; (2) lack of standardized decision-making processes for managing central venous catheters; and (3) oral communication holds it together. Our findings provide a foundation for the development of EHR functional requirements that enhance communication regarding the management of central venous catheters and facilitate the prompt removal of unnecessary lines.

Development and Validation of WeCares, a Survey Instrument to Assess Hospitalized Patients' and Family Members' "Willingness to Engage in Your Care and Safety".

BACKGROUND: Patient engagement is recognized as a method to improve care quality and safety. A research team developed WeCares (Willingness to Engage in Your Care and Safety), a survey instrument assessing patients' and families' engagement in the safety of their care during their hospital stay. The objective of this study is to establish the preliminary construct validity and internal consistency of WeCares. METHODS: WeCares was distributed to patients and families. With the survey responses, exploratory factor analysis (EFA) was performed to identify the factorial structure of WeCares. The internal consistency was assessed using Cronbach's alpha. Descriptive and comparative analysis was also performed to summarize patients' and families' responses. RESULTS: A total of 247 patients and families responded to the WeCare survey, of which 224 were used for EFA. EFA resulted in a 13-item, four-factor structure, including (1) comfortable sharing concerns, (2) responsibility for preventing errors, (3) perception of care team members' attitude, and (4) patients'/families' role in preventing errors. The Cronbach alphas were 0.716-0.866, indicating acceptable internal consistency. Overall, patients and families were comfortable sharing concerns with clinicians but preferred to remain anonymous. They believed that the care team members hold most responsibility for error prevention, however, and agreed on their ability to help prevent errors. CONCLUSION: WeCares was developed to assess patients' and families' willingness to engage. WeCares can also be used to facilitate conversation about safety concerns and shared responsibility. The study team believes this would lead to patient activation in guarding their own care and ultimately improve patient outcomes and safety.

Mixed-Methods Evaluation of Real-Time Safety Reporting by Hospitalized Patients and Their Care Partners: The MySafeCare Application.

OBJECTIVE: The aims of the study were to evaluate the amount and content of data patients and care partners reported using a real-time electronic safety tool compared with other reporting mechanisms and to understand their perspectives on safety concerns and reporting in the hospital. METHODS: This study used mixed methods including 20-month preimplementation and postimplementation trial evaluating MySafeCare, a web-based application, which allows hospitalized patients/care partners to report safety concerns in real time. The study compared MySafeCare submission rates for three hospital units (oncology acute care, vascular intermediate care, medical intensive care) with submissions rates of Patient Family Relations (PFR) Department, a hospital service to address patient/family concerns. The study used triangulation of quantitative data with thematic analysis of safety concern submissions and patient/care partner interviews to understand submission content and perspectives on safety reporting. RESULTS: Thirty-two MySafeCare submissions were received with an average rate of 1.7 submissions per 1000 patient-days and a range of 0.3 to 4.8 submissions per 1000 patient-days across all units, indicating notable variation between units. MySafeCare submission rates were significantly higher than PFR submission rates during the postintervention period on the vascular unit (4.3 [95% confidence interval = 2.8-6.5] versus 1.5 [95% confidence interval = 0.7-3.1], Poisson) (P = 0.01). Overall trends indicated a decrease in PFR submissions after MySafeCare implementation. Triangulated data indicated patients preferred to report anonymously and did not want concerns submitted directly to their care team. CONCLUSIONS: MySafeCare evaluation confirmed the potential value of providing an electronic, anonymous reporting tool in the hospital to capture safety concerns in real time. Such applications should be tested further as part of patient safety programs.

Applying User-Centered Design Methods to the Development of an mHealth Application for Use in the Hospital Setting by Patients and Care Partners.

INTRODUCTION: Developing an optimized and user-friendly mHealth application for patients and family members in the hospital environment presents unique challenges given the diverse patient population and patients' various states of well-being. OBJECTIVE: This article describes user-centered design methods and results for developing the patient and family facing user interface and functionality of MySafeCare, a safety reporting tool for hospitalized patients and their family members. METHODS: Individual and group usability sessions were conducted with specific testing scenarios for participants to follow to test the usability and functionality of the tool. Participants included patients, family members, and Patient and Family Advisory Council (PFAC) members. Engagement rounds were also conducted on study units and lessons learned provided additional information to the usability work. Usability results were aligned with Nielsen's Usability Heuristics. RESULTS: Eleven patients and family members and 25 PFAC members participated in usability testing and over 250 patients and family members were engaged during research team rounding. Specific themes resulting from the usability testing sessions influenced the changes made to the user interface design, workflow functionality, and terminology. CONCLUSION: User-centered design should focus on workflow functionality, terminology, and user interface issues for mHealth applications. These themes illustrated issues aligned with four of Nielsen's Usability Heuristics: match between system and the real world, consistency and standards, flexibility and efficiency of use, and aesthetic and minimalist design. We identified workflow and terminology issues that may be specific to the use of an mHealth application focused on safety and used by hospitalized patients and their families.

Implementation, evaluation, and recommendations for extension of AHRQ Common Formats to capture patient- and carepartner-generated safety data.

OBJECTIVES: The Common Formats, published by the Agency for Healthcare Research and Quality, represent a standard for safety event reporting used by Patient Safety Organizations (PSOs). We evaluated its ability to capture patient-reported safety events. MATERIALS AND METHODS: We formally evaluated gaps between the Common Formats and a safety concern reporting system for use by patients and their carepartners (ie friends/families) at Brigham and Women's Hospital. RESULTS: Overall, we found large gaps between Common Formats (versions 1.2, 2.0) and our patient/carepartner reporting system, with only 22-30% of the data elements matching. DISCUSSION: We recommend extensions to the Common Formats, including concepts that capture greater detail about the submitter and safety categories relevant to unsafe conditions and near misses that patients and carepartners routinely observe. CONCLUSION: Extensions to the Common Formats could enable more complete safety data sets and greater understanding of safety from key stakeholder perspectives, especially patients, and carepartners.

An informatics research agenda to support patient and family empowerment and engagement in care and recovery during and after hospitalization.

As part of an interdisciplinary acute care patient portal task force with members from 10 academic medical centers and professional organizations, we held a national workshop with 71 attendees representing over 30 health systems, professional organizations, and technology companies. Our consensus approach identified 7 key sociotechnical and evaluation research focus areas related to the consumption and capture of information from patients, care partners (eg, family, friends), and clinicians through portals in the acute and post-acute care settings. The 7 research areas were: (1) standards, (2) privacy and security, (3) user-centered design, (4) implementation, (5) data and content, (6) clinical decision support, and (7) measurement. Patient portals are not yet in routine use in the acute and post-acute setting, and research focused on the identified domains should increase the likelihood that they will deliver benefit, especially as there are differences between needs in acute and post-acute care compared to the ambulatory setting.

Quantifying and Visualizing Nursing Flowsheet Documentation Burden in Acute and Critical Care.

Documentation burden is a well-documented problem within healthcare, and improvement requires understanding of the scope and depth of the problem across domains. In this study we quantified documentation burden within EHR flowsheets, which are primarily used by nurses to document assessments and interventions. We found mean rates of 633-689 manual flowsheet data entries per 12-hour shift in the ICU and 631-875 manual flowsheet data entries per 12-hour shift in acute care, excluding device data. Automated streaming of device data only accounted for 5-20% of flowsheet data entries across our sample. Reported rates averaged to a nurse documenting 1 data point every 0.82-1.14 minutes, despite only a minimum data-set of required documentation. Increased automated device integration and novel approaches to decrease data capture burden (e.g., voice recognition), may increase nurses' available time for interpretation, annotation, and synthesis of patient data while also further advancing the richness of information within patient records.

Nurse, Patient, and Care Partner Perceptions of a Personalized Safety Plan Screensaver.

A patient safety plan dashboard was developed that captures disparate data from the electronic health record that is then displayed as a personalized bedside screensaver. The dashboard aligns all care team members, including patients and families, in the safety plan. The screensaver content includes icons that pertain to common geriatric syndromes. In two phases, interviews were conducted with nurses, nursing assistants, patients, and informal caregivers in a large, tertiary care center. End user perceptions of the content and interface of the personalized safety plan screensavers were identified and strategies to overcome the barriers to use for future iterations were defined. Many themes were identified, ranging from appreciation of the clinical decision support provided by the screensavers to the value of the safety-centric content. Differences emerged stemming from each group of end users' role on the care team. All feedback will inform requirements for improvements to the personalized safety plan screensaver. [Journal of Gerontological Nursing, 43(4), 15-22.].

Towards Analytics of the Patient and Family Perspective: A Case Study and Recommendations for Data Capture of Safety and Quality Concerns.

Safety reporting systems are improving our current understanding of safety in hospital settings, although mostly from the clinician perspective. Patient Family Relations (PFR) programs provide the opportunity to capture patient/family concerns in the hospital. Descriptive statistics were completed of PFR concern submissions over a 20 month period, as well as a comparison of structured data fields to those of the AHRQ Common Format. We identified statistically significant differences in rates of concern submissions, methods of submission, and role of submitter across patient populations. Overall, the most frequent concerns submitted to PFR were care/treatment and communication concerns. There was very little overlap of the PFR data elements with those of the AHRQ Common Format (overall rate of mismatch approached 80%). These results emphasize both the unique information that PFR data provides, as well as the need for enhancement and continuity of reporting systems for more effective analysis of safety data.