Opportunities to apply systems engineering to healthcare interprofessional education.

In medical settings, interprofessional education (IPE) plays an important role by bringing students from multiple disciplines together to learn how to collaborate effectively and coordinate safe patient care. Yet developing effective IPE is complex, considering that stakeholders from different schools and programs are involved, each with varying curriculum requirements and interests. Given its critical importance and inherent complexity, innovative approaches to address these challenges are needed to effectively develop and sustain effective IPE programs. Systems engineering (SE) combines a lifecycle perspective with established interdisciplinary processes to develop and sustain large complex systems. The need for SE approaches to manage healthcare complexity has been recognized, but the application of SE to IPE programs has been limited. We believe that there is a significant opportunity for IPE programs to benefit from the application of SE. The common themes running through SE and IPE led us to ask if SE can be used to address IPE complexity and achieve desired IPE outcomes. We believe that SE could facilitate further development and sustainability of a recently developed healthcare curriculum. We also propose to use SE to accelerate and manage future IPE curriculum development, while better understanding the states of vital IPE-related components. We discuss a framework that considers transitions of key IPE elements. We believe that use of interdisciplinary SE processes and holistic perspectives and methods such as system thinking will improve the management of system challenges while addressing IPE's inherent complexity and leading to better patient outcomes and more effective interprofessional collaboration.

Leveraging the Science of Teamwork to Sustain Handoff Improvements in Cardiovascular Surgery.

BACKGROUND: Improving the reliability of handoffs and care transitions is an important goal for many health care organizations. Increasing evidence shows that human-centered design and improved teamwork can lead to sustainable care transition improvements and better patient outcomes. This study was conducted within a cardiovascular service line at an academic medical center that performs more than 600 surgical procedures annually. A handoff process previously implemented at the center was poorly adopted. This work aimed to improve cardiovascular handoffs by applying human factors and the science of teamwork. METHODS: The study's quality improvement method used Plan-Do-Study-Act cycles and participatory design and ergonomics to develop, implement, and assess a new handoff process and bundle. Trained observers analyzed video-recorded and live handoffs to assess teamwork, leadership, communication, coordination, cooperation, and sustainability of unit-defined handoff best practices. The intervention included a teamwork-focused redesign process and handoff bundle with supporting cognitive aids and assessment metrics. RESULTS: The study assessed 153 handoffs in multiple phases over 3 years (2016-2019). Quantitative and qualitative assessments of clinician (teamwork) and implementation outcomes were performed. Compared with the baseline, the observed handoffs demonstrated improved team leadership (p < 0.0001), communication (p < 0.0001), coordination (p = 0.0018), and cooperation (p = 0.007) following the deployment of the handoff bundle. Sustained improvements in fidelity to unit-defined handoff best practices continued 2.3 years post-deployment of the handoff bundle. CONCLUSION: Participatory design and ergonomics, combined with implementation and safety science principles, can provide an evidence-based approach for sustaining complex sociotechnical change and making handoffs more reliable.

Team FIRST framework: Identifying core teamwork competencies critical to interprofessional healthcare curricula.

Interprofessional healthcare team function is critical to the effective delivery of patient care. Team members must possess teamwork competencies, as team function impacts patient, staff, team, and healthcare organizational outcomes. There is evidence that team training is beneficial; however, consensus on the optimal training content, methods, and evaluation is lacking. This manuscript will focus on training content. Team science and training research indicates that an effective team training program must be founded upon teamwork competencies. The Team FIRST framework asserts there are 10 teamwork competencies essential for healthcare providers: recognizing criticality of teamwork, creating a psychologically safe environment, structured communication, closed-loop communication, asking clarifying questions, sharing unique information, optimizing team mental models, mutual trust, mutual performance monitoring, and reflection/debriefing. The Team FIRST framework was conceptualized to instill these evidence-based teamwork competencies in healthcare professionals to improve interprofessional collaboration. This framework is founded in validated team science research and serves future efforts to develop and pilot educational strategies that educate healthcare workers on these competencies.

Improving the care of patients with COVID-19 with a medical student-run telemedicine clinic.

INTRODUCTION: In March 2020, the Dallas Fort Worth Metroplex experienced a surge in acute COVID-19 infections. At that time, no consistent protocols existed for follow-up of discharged patients with COVID-19 from the William P Clements Jr University Hospital at the University of Texas Southwestern Medical Center. Simultaneously, medical students were suspended from in-person clinical activities to limit viral spread. In response to these events, a telemedicine elective was created to provide timely and high-quality telehealth follow-up for recently discharged patients with COVID-19. METHODS: The pilot team, consisting of several second-year through fourth-year medical students, developed a call script that included warning signs and symptoms, Centers for Disease Control and Prevention (CDC) guidelines for isolation and primary care physician referral information. Patients with COVID-19 discharged from the emergency department (ED) and inpatient services were identified and assigned to student callers. All patients were discussed with an attending physician, who was available if an acute issue arose. The elective also included education on the SBAR (situation, background, assessment, and recommendation) handover technique, telehealth education, updated COVID-19 literature and CDC guidelines. RESULTS: Improvement was noted in students' ability to identify patients who required escalation of care, as seen by over 60% of patients who were advised to return to ED required hospital admission. Statistically significant improvement was observed in the students' degree of feeling informed about the current state of COVID-19 and their degree of comfort with interviewing patients over the phone. DISCUSSION: This elective provided quality virtual healthcare to patients with COVID-19 while allowing medical students to progress in their medical education and participate in patient care.

Empowering patients: simplifying discharge instructions.

Patients who do not have enough information about their discharge plans have decreased treatment compliance, decreased patient safety, increased emergency department (ED) recidivism, and poor satisfaction. This project aimed to develop and implement a method to assess and improve patient understanding of treatment and discharge plan in the ED. The authors developed a questionnaire to assess patient knowledge using Centers for Medicare and Medicaid Services and Joint Commission recommendations, areas of communication deficits reported in other manuscripts, and ED staff and provider input. Responses from patient interviews were then scored against the medical record. Three trained scorers graded all responses, and inter-rater reliability was calculated using the kappa statistic.Baseline observations found that written discharge instructions were long and tedious, and important information was difficult to find. Based on initial patient scores, stakeholder interviews, and fishbone diagrams, the team developed a one-page simplified information page (SIP) targeted to inform patients their most relevant discharge instructions. Next, the SIP was tested on 118 patients to measure its effect on patient understanding. At the baseline study, no patients had complete understanding of their discharge instructions. The areas of lowest scores were medication instructions and indications to return to the ED. Implementation of the SIP resulted in statistically significant changes in score distribution across all questions assessed with the Wilcoxon signed-rank test. Interrater reliability between scorers was high (kappa=0.84). We incorporated the concept of the SIP to the cover page of our standard discharge instructions.Healthcare providers often spend valuable time educating their patients, and it is important to assess the effectiveness of this teaching to identify areas in which we may improve health literacy and patient understanding. This project has shown that a simple, easy-to-read, concise page developed with patient input significantly improved ED discharge instruction knowledge.

An Implementation Science Approach to Handoff Redesign in a Cardiac Surgery Intensive Care Unit.

BACKGROUND: The ability of handoff redesign to improve short-term outcomes is well established, yet an effective approach for achieving widespread adoption is unknown. An implementation science-based approach capable of influencing the leading indicators of widespread adoption was used to redesign handoffs from the cardiac operating room to the intensive care unit. METHODS: A transdisciplinary, unit-based team used a 12-step implementation process. The steps were divided into 4 phases: planning, engaging, executing, and evaluating. Based on unit-determined best practices, a "handoff bundle" was designed. This included team training, structured education with video illustration, and cognitive aids. Fidelity and acceptability were measured before, during, and after the handoff bundle was deployed. RESULTS: Redesign and implementation of the handoff process occurred over 12 months. Multiple rapid-cycle process improvements led to reductions in the handoff duration from 12.6 minutes to 10.7 minutes (P < .014). Fidelity to unit-determined handoff best practices was assessed based on a sample of the cardiac surgery population preimplantation and postimplementation. Twenty-three handoff best practices (information and tasks) demonstrated improvements compared with the preimplementation period. Provider satisfaction scores 2.5 years after implementation remained high compared with the redesign phase (87 vs. 84; P = .133). CONCLUSIONS: The use of an implementation-based approach for handoff redesign can be effective for improving the leading indicators of successful adoption of a structured handoff process. Future quality improvement studies addressing sustainability and widespread adoption of this approach appear to be warranted, and should include the relationships to improved care coordination and reduced preventable medical errors.