Last Friday, Ida, Gerolf and I had a very instructive and thought-provoking meeting with one of the team members working on value-based care at the Uppsala University Hospital. The hospital is indeed in the process of optimizing its care-delivery processes in order to provide patients with both a better experience with hospital-based treatments and a higher quality of care. This relatively new, international “value-based” approach has its origins in the realization that hospital-based care processes lack efficiency and, from a patient perspective, objective ways to evaluate their quality. Statistics frequently used to assess the quality of the provided care include for example the number and the length of hospital visits, which the value-based approach argues are not actually representative of quality. More meaningful quality factors from a patient-centered perspective include for example how the patient feels, how quickly a diagnosis is established or whether the treatment is effective (whether the symptoms are effectively reduced by the treatment). As such, the value-based care optimization process aims to achieve quality in terms of patient-centered factors as well as provide valid measurements for the different factors taken into account, i.e. make it possible to evaluate the achieved quality level from a patient perspective. To carry out this high-level optimization process, the value-based care team at the Uppsala University Hospital is working together with inter-department groups of clinicians, for example in the form of workshops, in order to model the existing care flows and identify ways they can be improved as well as meaningful evaluation measurements.
Although those high-level organizational changes are beyond the scope of the DISA-project, it was important for us to get an insight into this change process currently taking place at the Uppsala University Hospital. Those workflow changes may indeed influence the documentation procedures (most of which are carried out digitally), and a good understanding of those procedures, their context and their purpose is essential in order to be able to interpret correctly what we will hear and observe while out in the field throughout the project.
Personally, I wonder whether a similar optimization could be applied to the doctors and nurses’ digital work environment. However, if patient-centered quality factors are relatively easy to come up with, the task is more complex when it comes to digital, nurse-centered processes. When it comes to computer-mediated documentation and, more generally, care delivery, what is quality? How can we assess and ensure that the existing digital workflows support nurses’ efficiency and well-being? I really hope that our work within the DISA-project will make it possible for us to answer those questions.
Jonas Moll and Åsa Cajander from HTO has worked together with a large group of researcher and the EU coordinators at Uppsala University in writing an application to Horison2020. We have been working on this and having meetings about this since the early fall, so this has taken quite a lot of time, and the application is around 14o pages of text including everything. This week the application was finally submitted, and it looks very good.
Writing this kind of large application requires good coordination, and we really had excellent coordinators this time which gives a good indication of the work in the future project.
If funded both Jonas Moll and Åsa Cajander will be working in the project and be in charge of one of the work packages.
Let’s hope that the application is granted!
Anticipating exactly what will resonate with your audience is not always easy. During the last couple of weeks I have been presenting some results from a study on the healthy digital workplace, as a part of the SISU-project. The presentations were part of the studied organisations change effort and my presentation was one part, embedded in the information from the organisations project leaders. The overall message was thus one of progress. The study I presented created a baseline for measuring the effects of the coming changes. It also indicated some strategic areas to observe during the change.
The one thing that really seemed to catch everyones attention was not so much the results as one of the slides I used to frame my message. In this slide I contrasted the idea of a linear progression from the current state to the next with the classic J-curve or change curve as it might be called (originally the Kübler-Ross model describing grief). The J-curve in this context is mainly a rhetoric tool, it presents a generic path through change, the big difference to the simple linear progression is the understanding that things will get worse, before they get better. As basic as this concept might seem, it did however seem to catch the interest of both managers and employees. It did seem as if it created a common ground for discussing the upcoming challenges.
As time was limited I did not expand on the concept however. Taken at face value it might be misunderstood as support for the idea of simple linear progression (A->B), just with a more bumpy road. In practice there are at least two waypoints that should be noted. The first is that there is a worst case scenario where there is no recovery and the change not only fails but even fails miserably (C). The second is that if the organisation navigates the turmoil it might still end up in some kind of status quo or rather same same but different (D). The promise of actual progress still needs to be fulfilled. Taking a note from Festinger’s theory of cognitive dissonance one might suspect that we might be tempted to rationalize our new position as an improvement without this actually being the case. Thus, we need to be careful to measure the right aspects during a change effort.
Finally, I didn’t use my favorite take on the change curve, namely the hype curve (hype cycle) made famous by Gartner. The inclusion of the hype is interesting as it puts focus on the rhetoric behind the change. Getting the boards interest and approval might well include some mild exaggerations regarding the benefits of the change. As is obvious from the hype curve the discrepancy between these promises and the coming turmoil might turn out rather dramatic. Thus, it is–as we all should know–important to manage expectations during change so as to avoid a roller coaster experience of change.
Come and work with us in the HTO research group. We are looking for a post doc for two of our action research projects.
The HTO group is going to be present at Vitalis 2017 which is one of the national conferences in health care. We will present in two different tracks this year:
- Medical Records Online (Journal via nätet – en maxxad tillställning). Jonas Moll will be presenting the latest results from the patient survey that was sent out in the summer. Åsa Cajander will be presenting together with Isabella Scandurra. We will also present our new Disa project to the audience in this track 🙂
- Envisioning Technology in Healthcare in 2015. Åsa Cajander will be presenting a project made in the IT in Society course together with Laura Wiegand, Mikaela Eriksson and Anna Normark.
There will be quiet many from the HTO group present at Vitalis, and we are all looking forward to an exciting trip 🙂
See you at Vitalis!
This spring we are doing a campus tour around Uppsala university to inform about the future changes that are coming up. As you might remember we have an action research project, Sisu, with the local Ladok implementation project, see this blog post .
The content of the seminars:
- Short presentation of project.
- Demonstration of the system.
- What is “digital workenvironment”
- Results from the survey “The digital work environment of study administrators”
- Some advice to the departments for handling this change
We have the following upcoming seminars planned:
7 april, 10.15-11.45. BMC, sal B/A 111a.
10 april, 13.15-14.45. Gamla torget, sal T/GT6_3576.
11 april, 12.15-13.45 Engelska parken. Geijersalen.
19 april, 12.30-14.00. Blåsenhus, Laborativa lärosalen. Med videolänk till Campus Gotland: rum B23.
You find updated infomration about New Ladok on the university information page
The ethics application I wrote about quite a while ago, regarding a new large observation/interview/survey study, has now finally been approved! This means that a new eHealth research adventure will now begin for the research team [Read more…]
Doing observation studies is not always as easy as it may seem at first glance, and Diane has already written much interesting stuff in her previous posts on the topic. I agree with her meta-observations, and I just thought I should add some of my views on this topic as well. My experiences are from my two days of observations on the children’s hospital, and the ward for children with tumour and blood diseases. Although the doctors and nurses work with very serious issues, I only experienced a very constructive atmosphere during my two days.
Most of the time when we visit the hospital environment we are there to receive treatment or visiting someone who is. We see a lot of things, and in some way they make sense. We see the blinking numbers on the wards, and we see the different screens used by the nurses and doctors. We see the white coats with blue stripes and don’t think more about that. But when we set out to actually study what is going on in this environment we not only have to see but also interpret the observations into scenarios. Even when we want to study a single system, and its effects on the work, it quickly becomes very evident that the workspace is a very entangled mesh of interactions between people and people and between people and machines. Some of these interactions are very short but nevertheless less important, and they are easy to miss if you are not focused. Some interactions are longer and thus also easier to observe. But in some cases, the more long-term interactions are also easy to miss because they are not continuous and thus have to be observed not only in terms of the shorter sequence as a whole (for instance, see example 2 below).
So, what do we see during an observation visit? Lots of things, but it soon becomes clear that the things we do not (normally) see, are just as important, if not more. Just to give two quick examples:
- In the ward, at every workplace there are two screens for logging into applications, such as Cosmic, and other supportive tools. What is not (easily) seen is the parallell information storage that is widely used by the nurses. After almost a day at the ward, I suddenly realised that all the nurses had a small paper notebook, which they consulted now and then. It was kept in the pockets of the coat but was very difficult to observe. When asked about it, the nurse told me that the notebook was used to keep track of the details about each patient. The notebook seems to be an important but almost externally invisible information carrier.
- Another observation that caught my attention, not because it was evident, but rather because it was not, was the role played by the alarm bell. The alarm has two functions, one that is an emergency call and the other, which is just a call for help with toilet visits or similar. Both are noted on the same display, and with similar sounds (still clearly easy to distinguish). However, the reactions to the alarms are completely different. In the second case, one or two nurses go over to the room, as soon as they are finished with their current tasks. In the first case, the work spaces are emptied within a few seconds. All tasks are interrupted, and almost everyone rushes to the room in question. Since they rush in the middle of a task, the software applications need to be extra supportive and help the nurse getting back into what he or she was doing. This is not something that is easily visible but could be of great importance.
These two examples show in a clear way that observations can be multilayered and need to be both seen and put into the work context. In the case of the notebook, it was also something that was not really thought of by the nurses; it was so integrated into their work that they never gave it any thought.
This makes on-site observation studies both important and interesting but also difficult at the same time. How to systematically get at these ”invisible” observations is a difficult matter, and from my experiences, I think it requires a long observation time to find many of them.
This week Jonas Moll and Åsa Cajander from HTO participated in a two-day conference with around ten other researchers from the DOME consortium. The consortium has done research on medical records online since 2012, and it is really a flourishing group of people. Recently DOME has received funding for several new research projects, and the Disa project is partly a part of DOME.
Åsa Cajander has written a short blog post of the work done during day 1 of the conference, and day two had a focus on the future of the consortium. You can also find some blog posts on DOME in Jonas Moll’s blog.
To make the discussion about the future of DOME, and a reframing of the objectives of the consortium we had engaged a professional facilitator from Gothia Science Park to help us. I must say that the person we engaged did an excellent job, and that we had very good discussions related to our work.
We started off the work with DOME’s future during day one when we were asked to write post-it notes in areas related to an inventory of our assessments. Day 2 we then started to work with the invetory of what we have in regards to results, networks, experiences etc. We worked in pairs and rotated in the room to put notes on the different topics on different sections of the wall. The whole room was especially designed for this kind of workshop, and to facilitate creative discussions.
When the inventory was done we moved on to doing a SWOT analysis, and to defining the objectives with the DOME consortium that needed to be updated and agreed upon.
We were also asked to write down our own objectives with being a part of the consortium, which revealed that we are indeed a group of people motivated by improvement of heath care. This exercise also showed that many of us have the same goals, and that there were no contradicting goals in the group.
This strategic work was indeed very motivating, and really something I strongly recommend to all research projects, networks or research groups.
As always it was excellent to meet the other DOME researcher, and I am really looking forward to our next meeting in the fall. Until then we collaborate using Slack, Skype and other collaborative technologies. Not as fun, but it works really well too. 🙂
The digital work environment refers to the problems and possibilities of both physical, psychosocial and cognitive nature which results from the work tools being digitalized. Digital work environment is one of the research areas of the HTO group, and several of the members of the group work with the TIGER project since a few years.
Bengt Sandblad is our most prominent and experienced reseracher in the area of digital work environments, and he claims that:
Many IT systems are illegal, and should be stopped!
What does he mean by this? Well, if the Working Environment Act was used properly many IT systems would be stopped and not used, he claims.
Professor Bengt Sandblad explores this further and is cited in this article found in Vårdfokus which is the nurses’ union’s magazine (in Swedish).
The article describes that IT in health care has serious usability flaws and one of the people interviewed , Kerstin Forsberg, chief of the Health Professionals at Skaraborg Hospital Skövde, thinks that the new Working Environment Act launched in 2016 will help in adressing these problems.
However, professor Bengt has serious doubts and says that the new regulations are not sufficiently detailed to specific deficiencies in the IT environment to be identified and addressed.
Bengt Sandblad emphasizes that better IT and working environment requires action by all parties involved. Workers need to aquire the skills required, and be sure to acquire knowledge to identify and tackle the problem. Employers and IT industry need to focus more on good digital work environment and the Work Environment Authority must become better at using the laws that are there to intervene.
If you are interested in reading more about professor Bengt Sandblad’s work in this area we recommend the following (also in Swedish):