Systematic Approach for Comparing Team-based Care Processes

Abstract

Team-based care process modeling techniques have focused on understanding and designing solutions for a single site. Less is known about tailoring an effective team-based care process from one site to another, which is necessary for multi-site implementation efforts. We propose an approach for analyzing and comparing a team-based care process performed at two sites to inform redesign opportunities. Our approach includes abstracting the goals and strategies of each process by identifying whether sociotechnical system element differences exist. Element differences may exist for the phase, tasks, roles, information, and technology and tools. Differences in system elements may still support process goals and strategies and, thus, be irrelevant for redesign opportunities. We demonstrate the utility of the approach using an operating room to intensive care unit handoff protocol. This approach should be useful for researchers and practitioners that are tailoring and implementing a successful team-based care process at more than one site.

INTRODUCTION

Human factors engineering (HFE) has developed approaches to improve team-based care processes (Holden & Carayon, 2021; Schultz, Carayon, Hundt, & Springman, 2007). Process analysis methods help HFE practitioners to understand complex processes that may be distributed over time and space and to identify redesign opportunities (Jun, Ward, Morris, & Clarkson, 2009). Process analysis methods decompose a complex process into sociotechnical system elements (e.g., phase, tasks, roles, information, and technology and tools) (Wooldridge et al., 2020; Wooldridge, Carayon, Hundt, & Hoonakker, 2017). While process modeling can be useful in supporting the implementation of a redesigned team-based care process and protocol in an individual setting (Holden & Carayon, 2021), there has been limited focus on translating processes effective in one site to another. Such translation efforts are necessary to achieve successful implementation of evidence-based processes, which is an increasing focus for learning health systems (Chambers, Feero, & Khoury, 2016) and biomedical research funders (Mensah et al., 2015).

One barrier to translating an effective team-based care process between sites is site-specific factors that impact process definition and execution. For instance, a goal for one process (e.g., training as part of an accredited program) may not be relevant at another. The physical environment (e.g., proximity of the operating room (OR) to the intensive care unit (ICU)) and availability of resources (e.g., medical devices) may impact one site but not another. Technology differences (e.g., electronic health record (EHR) and physical whiteboard) may impact alternative redesign opportunities. Staffing constraints can also impact the process one site but not another (e.g., number of roles involved in patient transport from the OR-to-ICU).

A second barrier to translation is that the goals for an existing team-based care process may not be documented. While the existing process may seem to work, it may not documented rationale about why it was designed or how it was implemented to accommodate site-specific factors. With incomplete documentation and personnel turn over, insights about process development and implementation may be lost.

Starting with a team-based process, this paper introduces a systematic approach to identify redesign opportunities to tailor the process at a second site. The approach includes abstracting the goals, strategies, and tactics of each process to identify if sociotechnical system element differences exist that nevertheless support the respective goal(s); thus, the differences may be irrelevant for redesign opportunities. We demonstrate the approach’s utility using an OR-to-ICU handoff protocol.

We describe our systematic approach for comparing a team-based care process occurring in two sites.

Step 1: Characterize current process

While each site has a process in place, the process description may need some refinement. For example, a checklist or procedure may not clearly describe all sociotechnical system elements. Thus, the first step is characterizing the current process of interest along with its sociotechnical system elements and their interactions.

The team-based care process may occur in multiple phases, each with varying goals. Each phase will require a different set of tasks to be achieved in one or more physical locations (e.g., OR and ICU). Different roles may be required to execute tasks in a specific phase (e.g., transport technicians may only be required in a phase where patients need to transition between units). Some tasks may be performed by individual roles (e.g., ICU nurse may get the infusion pump) and others by multiple.

A set of professional titles (e.g., advanced practice provider, APP, to those with different training and experience) may serve as the same role representative. The anesthesiology attending, anesthesiology resident, or certified registered nurse anesthetist (CRNA) can serve as the anesthesiology representative (Table 1).

Table 1.

Example professional title to role representative mapping

Role representative	Professional title
Anesthesia representative	(1) Anesthesiology attending (2) CRNA (3) Anesthesiology resident
ICU provider	(1) Critical care attending (2) Critical care fellow (3) Resident (4) Unit-based assistant (5) Unit-based nurse practitioner
Surgery representative	(1) Surgeon (2) Surgery fellow (3) Physician assistant (4) Intern

In practice, either the anesthesia resident or the CRNA can prepare necessary equipment for transport, such as the mechanical ventilator or Ambu bag with oxygen tank.

Roles executing tasks make assessments and decisions and generate and record different information for one’s and others’ use. Different technology supports information acquisition, analysis, storage, and dissemination. For example, the EHR system, whiteboards, and structured/unstructured sheets of paper can all support information processing needs.

Task execution involves medical devices and equipment to support data acquisition (e.g., vital sign monitor). Equipment can also support patient care delivery (e.g., ventilator).

Step 2: Abstract goals, strategies, tactics, and form

Processes are developed to achieve specific goals. The steps of the processes include exact methods or underlying strategies to achieve the goal(s). However, when subject matter experts generate process descriptions, the goals or strategies may not be articulated in the provided information. This is due to the fact that process descriptions generally describe the steps without the rationale for them. Thus, for each task, the researcher (i.e., analyst) may need to review the process description and abstract the specified goals and/or strategies. For example, a goal may be for the team members to know the identity and role of others, if they have additional questions afterwards. Strategies could include a synchronous two-way verbal communication such as with introductions, a real-time salient indicator on each person such as a large badge, or an easily accessible electronic or physical staff list with roles. Additional data collection may be required (e.g., interviews with subject matter experts) to understand the goals and their associated strategies.

Step 3: Multi-level comparison of team-based care process

Steps 1 and 2 facilitate a comparison to identify process differences at the goal, strategy, and tactic levels.

Sociotechnical system element comparison.

For each phase of the care process, the analysts should compare each abstracted sociotechnical system element (e.g., task and role assignments) to determine if they match. When different, the analysts should characterize the difference including identifying missing or additional sociotechnical system elements (e.g., two preparatory phone calls from the OR to the ICU instead of one phone call). Regarding role assignments, the analysts should compare what professional titles (e.g., anesthesiology attending and anesthesiology resident) are assigned to a role representative (e.g., anesthesia representative). For differences, the analysts should determine whether there are varying goals or strategies to achieve them.

Sociotechnical system element attributes.

Each sociotechnical system element will likely be associated with site-specific factors. For instance, staff census and schedule, that impact how often personnel work together; equipment and resources that may affect whether effort is needed to collect needed items; physical and electronic infrastructure that impact the strategies available to complete assigned work. Thus, it is important to identify any element level attribute differences. For example, a task may be required at one site or context but not in another. One may be time-sensitive and another able to be achieved at any time. A task may be high priority due to impact on the patient stability and another of lower importance. There may be physical environment constraints that limit task execution (e.g., the distance from the ICU to the OR). Such attributes are important to document as they may inform whether element differences can be addressed in the redesign.

Sociotechnical system element interactions.

In complex team-based care processes, there are interactions between elements; these should be identified and compared. There can be different assignments, such as:

• Task to phase: what task(s) occur in each phase

• Task to role: what role(s) are responsible to execute each task

• Task to information: what information is acquired, processed, and recorded in each task

• Task to technology and tools: what artefacts support each task

These differences should be compared with respect to whether they support achieving similar goals with different strategies.

Step 4: Identify opportunities for improvement

Although two sites may differ in how a process is designed and executed, not all the differences may be relevant, depending on the site-specific factors. Each element difference needs to be reviewed for relevance, depending on process goals. Comparing respective elements across two (or more) sites facilitates identification of necessary elements which can then inform design sessions with roles involved in the team-based care process. An understanding of necessary elements, to achieve process goals, combined with input from participating roles can help identify whether there are opportunities for redesigning the team-based care process to improve both process and outcome measures.

Step 5: Implementation

To determine whether process redesign opportunities can be feasibly addressed, an approach to implementation should account for site-specific factors.

Researchers conducting process redesign can concurrently identify barriers and facilitators to implementation through contextual inquiry. These barriers and facilitators are then addressed with a detailed implementation plan created in consultation with involved roles and that considers site-specific individual, team, and organizational factors (Fernandez et al., 2019). Design sessions can provide a mechanism to review opportunities for redesign and input from roles involved in the team-based care process.

CASE STUDY APPLICATION – OR-TO-ICU HANDOFF

We report a case study (Yin, 1999, 2018) focusing on our approach for identifying process differences between two sites’ OR-to-ICU handoff processes. Study approval was obtained from the IRB at the University of Pennsylvania (#843670).

Site setting

The first site is an urban academic medical center and is an accredited level 1 trauma center with 375 beds. The second site is an urban level 2 trauma center with 420 beds.

Process description

As part of a larger study (Lane-Fall et al., 2021), two researchers interviewed four different roles involved in the OR-to-ICU handoff: CRNA, ICU nurse, ICU APP, and surgeon. They abstracted sociotechnical system element data using a structured Microsoft Excel^® spreadsheet and developed process maps in LucidChart. The two LucidChart process maps included five sociotechnical system elements (Table 2) and were structured with columns representing phases, and rows representing the different roles participating in the OR-to-ICU handoff. Each phase included one to nine tasks with icons representing medical devices and other equipment. The process maps used role representatives as the elements assigned tasks. The mapping of role representatives to professional titles was captured using footnotes describing acronyms and professional titles for role representatives.

Table 2.

Sociotechnical system element examples for two sites.

Elements	Site 1	Site 2
Phase	Handoff preparation Physical transport of patient Arrival Huddle of clinicians	Handoff preparation Physical transport of patient Huddle of clinicians
Task	Communication about OR team’s ETA to ICU Surgery representative communicates intraoperative events	Communication about OR team’s ETA to ICU Introductions Surgery representative communicates intraoperative events
Role	Anesthesia rep. ICU nurse ICU provider Surgery rep. Transport tech.	Anesthesia rep. ICU nurse ICU provider OR circ. nurse Surgery rep.
Information	Role identification Intraoperative events	Intraoperative events
Technology and tools	EMR ICU bed board Infusion pump	EMR ICU bed board Infusion pump

Notes: estimated time of arrival, ETA; representative, rep.; technician, tech.; circulating, circ., electronic medical record, EMR.

Bold text indicates Site-1 specific examples; italics text indicates Site-2 specific examples; regular text indicates examples in both sites. Phase, task, information, and tools and technology are listed in the order they appear on the process map; roles are listed in alphabetical order.

Step 1: Characterize current handoff process

Site 1’s handoff process includes nine phases, 23 tasks, nine roles, and eight medical devices and other equipment. Site 2 includes six phases, 19 tasks, eight roles, and eight medical devices and other equipment. Both sites had multiple professional titles able to fulfill certain roles.

Step 2: Abstract goals, strategies, tactics, and form

Two researchers reviewed the sociotechnical system elements and discussed the respective goals, strategies, and tactics for each task. Often, the tactics were the same as the task description (Table 3).

Table 3.

Process element comparison for goals, strategies, and tactics.

Sites	Phase	Task	Role representative	Goals	Strategies	Tactics
1,2	Handoff preparation	Communication about OR team’s ETA to ICU	1: Anesthesia rep. 2: OR circ. nurse ICU nurse	Provide an indication to ICU team about upcoming patient delivery	Two-way synchronous communication	Phone call
1,2	Physical transport of patient	Monitor vital signs and administering medications (as needed)	Anesthesia rep. Surgery rep. 1: Transport tech. 2: OR circ. nurse	Safely move patient from OR to ICU Ensure continuation of patient care	3-role (moving patient bed, environmental tasks, administering meds) team physical transport	3-roles required
1	Arrival	ICU secretary announces over PA system swarm and patient’s bed number	1: Anesthesia rep. 1: Surgery rep. 1: ICU secretary	Provide an indication about patient’s arrival to ICU	One-way synchronous communication	PA system
1	Huddle of clinicians	Introductions	Anesthesia rep. ICU nurse ICU provider Surgery rep.	Role identification Establishing inter-personal relationships	Two-way synchronous, co-located communication
1	Huddle of clinicians	ICU nurse, ICU provider, or surgical rep. initiates handoff by asking if everyone is ready	Anesthesia rep. ICU nurse ICU provider Surgery rep.	Initiate communication Verify patient stability	Two-way synchronous, co-located communication Additional team members (secondary nurses) managing patient care

Note: estimated time of arrival, ETA; public address, PA; representative, rep.; technician, tech.; circulating, circ., electronic medical record, EMR.

Bold text indicates Site-1 specific; italics text indicates Site-2 specific; regular text indicates both site-specific.

Unless specified, the tactics are the same as the task.

Step 3: Multi-level comparison of team-based care process

Sites 1 and 2 share similar tasks within the handoff preparation and physical transport of the patient phases (Table 3). In handoff preparation, both sites include a task for communication about OR team’s estimated time of arrival to ICU. In physical transport of the patient, both sites have three roles involved in moving the patient bed, monitoring the patient’s vital signs, and administering medications.

Site 1 has an additional task (within huddle of clinicians phase), for introductions. Site 2 does not have an introduction task because the unit has fewer beds, and therefore the personnel are already familiar with each other. This difference highlights that some sites may not require introductions because the ICU team is more familiar with each other, possibly due to the setting (e.g., a burn ICU as compared to a trauma ICU). In contrast, other sites may require introductions because the ICU team is less familiar with each other (e.g., large academic medical center with rotating trainees). At the goal level, this difference means that the need for ensuring that the staff know each other, and their roles is unnecessary when members of smaller units inherently have this knowledge.

As shown in Table 3, Site 1 has an additional phase for arrival with the ICU secretary announcing the patient’s arrival over the PA system. The one-way synchronous communication does not occur in Site 2 because of its physical environment (i.e., ICU layout configuration).

The patient rooms in Site 2 are closer together, due to the architectural shape of the building, so ICU team members can hear when the patient arrives. In contrast, the patient rooms in Site 1 are more spread out, thus requiring the additional phase for arrival and role of the ICU secretary to make an announcement over the PA system.At the goal level, the need to announce the patient arrival is only necessary when perceptual cues are not already available in the environment.

At one site, the architecture of the ICU coupled with its smaller sizer meant that the staff always knew when the patient arrived, eliminating the need for this phase and task as well as the associated role for the unit secretary in the handoff process.

Step 4: Identify opportunities for improvement

The differences between Sites 1 and 2 were related to two tasks, introductions and announcement of the patient arrival where the latter was associated with an additional role (i.e., ICU secretary) and phase (i.e., arrival). A superficial analysis indicated differences but determining the goals and strategies illustrated that the processes matched at the relevant goal levels. While these differences are not relevant for redesigning the OR-to-ICU handoff process, they are important for understanding site-specific factors.

Step 5: Implementation

If opportunities for redesign surface in Step 4 were identified, then the next step is to conduct design sessions at each site, with clinicians involved in the OR-to-ICU handoff. During the design sessions, it is important to review the current process as well as the barriers and facilitators to the OR-to-ICU handoff (e.g., negatively impacting team communication) in order to refine redesign opportunities. Implementation mapping (Fernandez et al., 2019) can be used to identify barriers and facilitators of implementation, as we design and tailor the OR-to-ICU handoff process.

DISCUSSION

We have developed a systematic approach for comparing two (or more) sites’ OR-to-ICU handoff process. To our knowledge, no other study that developed a team-based care process map presents a taxonomy for describing process differences (Schultz et al., 2007; Wooldridge et al., 2020). Our approach utilizes process maps, for the same team-based care process, developed for two (or more) sites.

The multi-level comparison provides a taxonomy for identifying process differences across two sites. Analyzing each site’s goals, strategies and tactics for sociotechnical system elements allows for identification of site-specific factors embedded within the process. Understanding the site-specific factors is necessary for identifying relevant and irrelevant redesign opportunities. The preservation of elements necessary for care process effectiveness (i.e., relevant elements) is paramount in multisite implementation efforts, which aim to improve outcomes through adherence to evidence-based practice. Adherence to the evidence-based care process is the mechanism through which care process-based improvements in patient and team outcomes occurs. For successful implementation however, each care process must be implemented in a site with site-specific factors. The approach articulated here enables identification of sociotechnical system elements that may be safely customized (i.e., irrelevant elements) without compromising the integrity of the evidence-based practice, and so may be useful to researchers and practitioners interested in tailoring and implementing a successful team-based care process at one (or more) sites.

Our multi-level approach for comparing a team-based care process occurring at two sites may be useful for knowledge elicitation. Researchers should consider sociotechnical system elements goals, tactics, and strategies when asking questions to inform redesign efforts and implementation mapping. One topic that arose in this work is that the goals and strategies used at each site were typically not part of the discussion of the procedure. In this work, the researcher (i.e., analysts) asked the subject matter experts (i.e., roles involved in the team-based care process) about the rationale for the goal behind each process task. The strategies, however, were not as transparent to the subject matter experts. For example, ideas surrounding the type and synchronicity of the communication as well as the permanence of the data storage were not consistent with how the subject matter experts expressed the process tasks. Better knowledge elicitation methods as well as archiving of process rationale may better support this approach.

The approach and taxonomy for comparing two sites OR-to-ICU handoff process may be generalizable to other team-based care processes. However, the sociotechnical system element differences that we identified in our single case study may not be generalizable for other OR-to-ICU handoff processes.

The results from this study suggest several directions for future work between human factors engineers and implementation scientists. First, identifying sociotechnical system element differences can be repeated for multi-site implementation studies tailoring a process to support care team members working collaboratively to provide high-quality, safe patient care. Second, additional data collection methods, as part of the larger study, can be used to conduct member checking for providing feedback on process components. For example, selected care team members involved in the handoff process could participate in a design session and first review and discuss the site’s process differences. Third, during interviews with handoff participants, researchers could ask about individual task decision making.

CONCLUSION

We introduced a multi-level approach and taxonomy for comparing the same team-based care process conducted at two sites. Our approach and taxonomy allow researchers and practitioners to identify site-specific factors embedded in the current OR-to-ICU handoff. Understanding site-specific factors may be useful before implementing and tailoring an evidence-based care process from one site to another site.