Enhancing healthcare process design with human factors engineering and reliability science, part 2: applying the knowledge to clinical documentation systems

Boston-Fleischhauer C. Enhancing healthcare process design with human factors engineering and reliability science, part 2: applying the knowledge to clinical documentation systems. J Nurs Adm. 2008 Feb;38(2):84-9.

The object of the article is to describe the application of human factors engineering and reliability science to clinical documentation. The article discusses specific implementation strategies and results as well as the organizational challenges presented and the executive responses.

The article defines human factors engineering, HFE, as “the discipline that studies human capabilities and limitations and applies that knowledge to designing safe and effective products, processes, and systems for human beings to successfully use.” Reliability science is defined as “the ability of an operation to be failure or defect free over time”. They are both new both defined as new bodies of knowledge.

The article goes on to discuss the challenges of the status quo of design and implementation. The challenges discussed are organized into six topics that include: confirming the desired workflow, populating model with relevant evidence as system defaults, considering the work environment, enhancing training efforts by having an education and training strategy that fits into the context of the work environment, using small test of change, and reevaluating the go-live and post go-live strategy.

• On the topic of confirming the desired operation workflow, data flow is discussed. Detailing the importance of analysis of the circumstances under which the data is being collected, what is required, what is relevant and making sure to construct a documentation system that is complementary to these goals of meeting requirements and demonstrating relevancy. This initial analysis may add to the upfront cost in time and dollars of the system, but will be paid returned in a more efficient, accurate system as less staff created work-arounds created as a by-product poorly designed system.

• On the topic of populating modules with relevant evidence built as default, the article discusses a number of ways to leverage a system to obtain clinician compliance with evidence-based practice systematically. By providing default entries, check lists, and screen flows that make it clear what item needs to be reviewed or filled in before progression to the next step in the workflow is extremely important in the successful implementation and adoption of a system.

• On the topic of work environment, a successful system will take into account the work environment in which it will reside. Understanding that the clinicians’ environment is a chaotic one, there are strategies that can be used to mitigate risk of inaccuracy in data entry, like the placement of the workspace, the lighting and creation of some privacy when possible. Also designing the system to minimize user memory load, leveraging standardization in information, commands or functions, as well as incorporating proximity compatibility and redundancy.

• On the topic of development of an education strategy, the article discusses the correlation between how much of an investment is made in training and the ways in which that investment pays off in the systems utilization after implementation. That this training should be conducted in a holistic manner, showing all modules integrate not just teaching a specific clinician his or her module. Seeing how the modules work together and how they support the workflow allows for the clinician to understand the relevancy of what they are doing in the system and also allows for a deeper understand of the system. This deeper understanding leads to more cognitive connection and retention of the material presented in training.

• On using small tests for change during the system implementation, allows for errors in design or inefficiencies that impact workflow to be discovered earlier, while it is easier to make changes. Also conducting pilot test with actual user in their work environments is a much better indicator of the success or failure of design then similar test done within a training/testing lab only.

• Lastly on Go-live strategy and post go-live includes not assuming that the moment the system is turned on is this the end of your implementation. Rather this is the start of the next phase of the IT implementation. This next phase will include product and process refinement.

The article concludes by stating that human factors engineering can be applied to clinical documentation system design and implementation, adding value and creating high quality applications.

Reviewed by Christine Klein for BMI512 Spring 2008