August 28, 2012
New Care Model Copes with Interruptions Better
A lot can be learned by simply taking time to observe workflows in a healthcare setting. Some time just go to a patient care unit and watch a nurse as he/she tries to carry out typical daily tasks. You, of course, see interruptions for answering call bells. And on the way back from that patient room you see a visiting family asking the nurse for directions to the cafeteria. Then Radiology calls the nurse to note that the physician did not correctly fill out the CT scan requisition so the nurse now has to track down the physician. A physician then interrupts the nurse to ask where patient X has gone. Another physician calls the floor to give a verbal order so the nurse has to take that order and enter it into the computer. Yet another physician calls to ask the nurse to look up the result of today’s INR so the warfarin order can be given. And the nurse has to walk to the other end of the unit to get some supplies to carry out a patient task. And the problem is even worse on weekends. Our December 15, 2009 Patient Safety Tip of the Week “The Weekend Effect” noted how the lack of non-nursing staff on weekends actually adds both considerable workload and interruptions to nursing staff. We have also seen that clerical staff have often been reduced or eliminated in the recent economic downturn, further accentuating the problem of interruptions for nursing staff. The nurse now ends up doing not only nursing jobs but clerical tasks as well. Even housekeeping tasks. It’s a wonder nurses can get any patient care activities done!
Several of our prior Patient Safety Tips of the Week have dealt with distractions and interruptions and their impact on patient safety and patient care (see list at end of today’s column). Interruptions and distractions affect nurses, physicians, pharmacists and not just “clinical” staff but really all healthcare workers. Our August 25, 2009 Patient Safety Tip of the Week “ ” highlighted some excellent studies on interruptions and distractions in healthcare. In that we provided references to some good statistics about the frequency and nature of interruptions and distractions and listed some recommendations about how to avoid them. Our May 4, 2010 Patient Safety Tip of the Week “More on the Impact of Interruptions” cited an excellent article on the impact of interruptions on medication administration errors (Westbrook 2010). That article also had a good discussion of strategies to minimize interruptions and future directions for research on reducing the occurrence of interruptions.
But despite a good literature on causes and contributing factors, it’s very difficult to find good studies showing interventions that successfully reduce interruptions and improve patient care. Interventions such as hourly rounding (see our July 26, 2011 Patient Safety Tip of the Week “Hourly Rounding”) which, when done well, not only improves patient satisfaction but also reduces nurse interruptions and may improve patient safety outcomes.
An innovative program at University of Pittsburgh Medical Center (UPMC) appears to have been successful in improving care while handling interruptions (Kowinsky 2012). As part of a quality improvement initiative they brainstormed and identified factors contributing to inefficient workflow, identified potential ways to address these, simulated a potential solution and then piloted the solution on one unit.
Their analysis basically categorized two types of work: “predictable” and “unpredictable”. The predictable work occurs repetitively and reliably and can be scheduled. This includes things like rounding, feeding, repositioning, vital signs, etc. The unpredictable work consists of tasks that tend to occur randomly over the course of the day and includes things like answering call bells, blood draws, transporting patients, handling admissions and discharges, etc. Because of the two types of work they created two types of roles to deal with them. The “reliable rounder” addressed the predictable work and the “variable rounder” addressed the unpredictable work. During the simulation exercise carried out on an unoccupied available nursing unit, they developed scenarios and scripts and had observers watch and critique those doing role-playing. Frontline nurses participated with leaders and quality improvement staff and provided feedback to improve the model. They then piloted the new model on a telemetry unit. It was budget neutral since the same number of personnel was required as in the old model. The model was well received by hospital staff and at both 90 days and one year there were significant improvements in call bell response times, blood collection times, and other quality/service metrics.
This is a very interesting concept and the work is an example of a very well done quality improvement project. We encourage you to read the full article about the project.
It is interesting that this solution involved splitting up tasks. Another recent study (Tremblay 2012) suggests that in complex dynamic situations working in small teams confers more resistance to task interruptions. The biggest problems with interruptions, of course, are that we often skip steps when we resume the task and the task may take longer. These researchers found, in a firefighting simulation, that teaming up resulted in faster resumption times but only if both team members were interrupted at the same time. It would be of interest to evaluate this in healthcare settings or at least simulations.
Another recent paper (Colligan 2012) applies a human factors approach to decreasing interruptions at a centralized medication station. This article describes some inexpensive barriers used to protect tasks that are vulnerable to interruption while preserving sight lines, staff situational awareness, and staff and patient/family collegiality.
Other interventions might include cordoning off an area and make it a “no-interruptions zone” when a nurse is preparing, dispensing, administering, or otherwise handling medications. Well-placed signage or good hospital services brochures may help minimize interruptions for giving directions. A whiteboard showing where patients have gone may reduce some of the physician interruptions. And making sure physicians have remote access to the patient record can minimize those calls where the nurse has to do the searching. And making sure that your system allows the Lab or Radiology to directly contact physicians for clarifications or reporting urgent results can avoid the unnecessary “intermediary” role of the nurse.
In many cases physicians are the source of the interruptions. In fact, when a “Do Not Disturb” sign was piloted to assist medication administration by nurses (Pape 2005), all sorts of interruptions decreased with one exception: interruptions by physicians! Another study (Tomietto 2012) showed a multi-intervention program to reduce interruptions (that included wearing the red tabard during medication administration rounds) paradoxically reduced interruptions by patients but staff member interruptions increased! Interestingly, these are examples of some of the more subtle behaviors Lucian Leape refers to in his recent theme on our culture of disrespect (see our July 2012 What’s New in the Patient Safety World column “A Culture of Disrespect”).
And as we design interventions to reduce interruptions and their impact, we must balance these against any negative impact they might have on patient satisfaction. In the UK there was some pushback from patient advocacy groups when nurses began wearing the red “Do Not Interrupt” tabards during medication administration.
Sometimes simply taking the time to stand back and examine your workflows is a great patient safety exercise. If you work on reducing interruptions and distractions in your environment, we guarantee you will see not only gains in productivity and both patient and staff satisfaction but you will also see error rates decline and patient outcomes improve. Creative solutions, such as the one implemented in the Kowinsky paper, are best developed by those directly impacted by interruptions and distractions. Having your frontline staff involved in identifying the root causes of those interruptions can lead to creative solutions.
Prior Patient Safety Tips of the Week dealing with interruptions:
Westbrook JI., Woods A, Rob MI., Dunsmuir WTM, Day RO. Association of interruptions with an increased risk and severity of medication administration errors. Archives of Internal Medicine. 2010, 170(8): 683-690.
Kowinsky AM, Shovel J, McLaughlin M, et al. Separating Predictable and Unpredictable Work to Manage Interruptions and Promote Safe and Effective Work Flow. Journal of Nursing Care Quality 2012. 27(2): 109-115, April/June 2012
Tremblay S, Vachon F, Lafond D, Kramer C. Dealing With Task Interruptions in Complex Dynamic Environments: Are Two Heads Better Than One? Human Factors 2012; 54: 70-83
Colligan L, Guerlain S, Steck SE, Hoke TR. Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station. BMJ Qual Saf 2012; Published Online First 14 August 2012
Pape TM, Guerra DM, Muzquiz M, et al. Innovative Approaches to Reducing Nurses’ Distractions During Medication Administration. Journal of Continuing Education in Nursing 2005; 36(3): 108-116 May/June 2005
Tomietto M, Sartor A, Mazzocoli E, Palese A. Paradoxical effects of a hospital-based, multi-intervention programme aimed at reducing medication round interruptions. J Nursing Management 2012; 20(3): 335-343