Value-based care at the Uppsala University Hospital

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.

First observation day, part 2: the perks of immersion

When it comes to analyzing work practice, I have found that one of the main challenges for the researcher is to learn to “speak the language” of the observed population. The researcher needs to develop an understanding for those aspects of the work practice that practitioners don’t explicitly mention, but which nonetheless are a significant part of their work and work environment. The problem is that the more experience we have with doing something, the more difficult it becomes to verbalize how we go about doing it. In addition, many work environment factors are simply difficult to put into words.

Observation provides, to a certain extent, a solution to that problem as it makes it unnecessary for the observed individuals to verbalize every aspect of their work. Until recently, my experience with observation within healthcare was limited to watching video recordings of emergency medical interventions and a live streaming of an open-heart surgery. Those instances provided me with a basic understanding of the workflow of an operation and the specific role taken on by each clinician involved in the intervention. However, I realized during my observation day at the Department of Pediatric Surgery that I had overlooked several essential factors specific to the work environment of clinical nurses. This realization came from the fact that for the first time, I wasn´t an outsider looking in any more, but immersed in the work environment I wanted to learn about. This made for a very different, and instructive, experience.

Here are the different “perks” I have identified in relation to my immersion into nurses’ work environment:

  • More than just a clinical understanding for nurses’ work environment, I got an insight into the “feeling” of it. By wearing the same clothes, sharing the same space and following the same daily routine as nurses, I was able to experience, albeit to a limited degree, how it feels like to be a nurse. This led to my uncovering aspects of the work environment I had not thought of so far.
  • Being a participant observer, I felt that I disposed of a higher degree of freedom when it came to deciding what to focus on. I was able to move freely within the operation theatre (being of course careful not to be in anyone’s way in order not to disrupt anybody’s workflow) and could choose what and whom to focus my attention on. While it is the camera’s positioning that determines and limits the field of vision on a video recording, immersion makes it possible to continuously change observation angle and thus to look at anything that catches one’s attention.
  • In contrast to my previous experiences with video recordings, where one generally only has access to a specific sequence of the work practice of interest, I got a much more complete picture of the workflow this time around. Being there for a whole day, I was able to see not only how an operation unfolds, but also, among other things, how an operation theatre is prepared, how nurses are made aware that the operation is about to begin as well as what happens in the operation theatre once the patient has left. This gave me a better and more accurate understanding of the context in which operations take place at a hospital.

In my next and last blog post within this short series of posts about my first experience as a participant observer, I will address a few aspects that I felt were a bit more challenging in regard with being out on the field.

First observation day, part 1: facilitating interactions

Last week, I had my first observation day at the Uppsala University Hospital, more specifically at the Department of Pediatric Surgery. After introducing myself to the nursing staff attending the morning briefing, I was invited to spend the next few hours in company of an operating nurse and an assistant nurse working in tandem in one of the department’s operation theatres. The purpose of this observation day was not to formally collect data for a study, but rather to familiarize myself a bit more with nurses’ work environment in preparation for the DISA project. This first experience as an observer has led me to reflect on different aspects related to being out on the field as a researcher. I thus thought that I would write a short series of blog posts to share those reflections with you. This first post within the series is dedicated to interactions between researcher and members of the “target population” – and how I feel that observation facilitates this kind of exchanges.

Throughout my observation day, what struck me the most was probably how easy it was to interact with the nurses present – how friendly and open they were to my being there, and how naturally exchanges and conversations took place, even at unexpected moments.  For instance, an anesthetic nurse told me about a problematic aspect of using multiple digital systems while quickly fetching a cup of tea in the personal lounge, and another nurse expressed how energy consuming the introduction of a new system was while passing me in the corridor. Coffee breaks and downtimes during operations (for example while waiting for lab test results) were opportunities for longer conversations with the operating nurse and the assistant nurse I was paired with. During those conversations, I was even able to ask specific questions about what I had seen or heard, which gave me a more accurate understanding of how nurses use and experience IT systems in their daily working life.

As such, I realized that a very significant advantage of being an observer was that I was making myself available to the department´s nurses on their own terms. While interviews typically require participants to come and talk to the interviewer at a specific time and during a pre-determined duration, observation lets them free to choose whether they want to interact with the researcher. If they are willing to do so, they can do it knowing that they are the ones choosing what the conversation is about and how long it lasts, being free to interrupt the discussion and resume their work at any moment. I felt that this was a sort of “win-win” situation for the nurses and I, as they had the possibility to tell me about the aspects of their work with digital systems that they felt were significant without additional stress or constraints while I was able to get an in-depth insight into their work and work environment.

In my next post, I will address another aspect of observation that I experienced as particularly positive: the immersion into the work environment.

Live-streaming of an open-heart surgery

In order to familiarize myself a bit more with the medical domain in preparation for the DISA project, I decided to attend the lectures of the “Medical Informatics” course given at the IT department at Uppsala University. The course comprises several study visits, the first one of which consisted in attending a live-streaming of an open-heart surgical intervention at the Uppsala University Hospital.

The live-streaming, which consisted of a high-quality video feed without sound, was orchestrated and commented by a clinician. Before and throughout the three hours that lasted the streaming session (which, unfortunately, ended before the end of the actual operation), the clinician provided us with some background on the ongoing procedure and explained to us how the main machinery and tools in use during the operation worked – showing us real-life examples of what these tools look like.

Throughout the streaming session, we had access to three different cameras located at different places in the operation theatre and capturing different angles of the intervention. As such, there were three different “views” available:

  • the operation theater as a whole, where we could see who was present in the room and how the medical staff was standing around the patient;
  • the “surgeon’s view”, where we could see the (opened) chest of the patient, as if standing above the patient’s body;
  • the vital signs monitor.

The main view used during the streaming session was the second one, the “surgeon’s view”. However, we switched several times to the general, operation theatre view, though for shorter amounts of time.

The live-streamed intervention revolved around placing an artificial valve inside the patient’s heart. In order to do this, the clinicians needed to:

  • Open the patient’s chest (including the chest bone);
  • “Connecting” the patient to the heart-lung machine (described in more detail below);
  • Stop the heart;
  • Open the heart;
  • Fix (with stitches) the artificial valve inside the heart;
  • Close the heart (with stitches);
  • Restart the heart (a defibrillation was needed);
  • Make an ultrasound of the heart (in order to check that the valve was working and well-adjusted);
  • Set up draining tubes (in order to allow for the bleeding within the heart cavity taking place during the next few hours after the operation to be drained out of the body without re-opening the chest);
  • Close the patient’s chest – a last step that we were unfortunately unable to witness.

To me, one of the most fascinating aspects of the surgery was the heart-lung machine. Its first function is to cool the patient’s blood (and, ultimately, the patient’s body) in order to minimize the risk of brain damage during the operation (which can be quite long). Its second, and probably main, function is to act as a substitute to the patient’s heart and lungs so as to enable the heart to be stopped while maintaining the patient alive. The heart-lung machine is handled by a specially trained nurse (called “perfusionist” in Swedish and “perfusion technologist” in English), who disposed of a screen (in addition to the machine’s two interface screens) with a specific MetaVision layout fitted to her particular needs.

Beyond the perfusion technologist, sitting at the heart-lung machine situated at some distance from the foot of the patient’s bed, the medical team actively taking part in the operations was composed of a main surgeon, an assistant surgeon, an operating nurse (notably in charge of handing instruments to the surgeons), an assistant nurse (notably in charge of handing equipment and instruments to the operating nurse) as well as an anesthetist and an anesthetic nurse. Interestingly, the anesthetist and the anesthetic nurse, standing at the head of the patient’s bed, were separated from the surgeons by a sort of curtain placed vertically between the chest and the head of the patient.

I noted two further interesting facts from the streaming. First, all team members except for the main surgeon are replaced at some point during the operation in order to prevent the risk for distraction- and tiredness-induced errors. As such, good “transfers of duty” seem to be an essential part of such complex and long interventions. Second, the surgeons and operating nurse did not seem to use any screen as support, and it is the anesthetist who is responsible to look at the result of the ultrasound in order to assess whether the result of the operation is satisfactory.

In summary, this was a truly fascinating and instructive “class”, though I was a bit disappointed by not having any sound – I had hoped to be able to hear how the medical team communicates and to understand when and how they use the different screens and computerized tools they are surrounded with. Hopefully I will get the opportunity to attend another operation within the next few years in order to answer those questions!

A (first) closer look at the outcome of the DISA project

The main goal of the DISA project is, according to the project application, the “creation a framework for decision support when new ICT solutions are to be implemented in healthcare […]”. However, this formulation leaves room for many questions. For instance, what decision-making process should this framework support? Who is expected to be using the framework? And what is the actual expected benefit of using this framework? In order to try and answer some of those questions, Ida and I arranged a meeting with the chief digital officer at the Uppsala University Hospital.

We learnt that the University Hospital is at the beginning of a phase of significant organizational changes, including, but not limited to, the implementation of a new digital strategy. There is a clear will to ensure that all IT-projects carried out in the future will effectively contribute to increasing the quality of care at the University Hospital. This should be achieved through a centralized project management and a systematized project application process. Concretely, this means that all project applications will be screened according to a framework composed of four different dimensions:

  1.   the project’s impact on work quality;
  2.   the project’s impact on work productivity;
  3.   the degree of risk related to the project;
  4.   the amount of resources needed to carry out the project.

The aim of this framework is to enable decision-makers at the department of digital development to select and prioritize IT-projects in an effective and efficient manner. The idea is also to push project applicants to motivate their project not based on technology (as in “I need an iPad”), but rather in terms of what needs to changed / improved in the affected work process (as in “I need to be able to see this data and discuss them with the patient while standing next to the patient’s bed”).

In light of this, we can re-interpret the end goal of the DISA project more as the identification and, probably, prioritization, of key factors related to the assessment of a project’s impact on nurses’ work environment than as the creation, from scratch, of a brand new decision-support framework. On the contrary, it seems at this point that finding a way to integrate the perspective of nurses’ work environment into the project assessment framework presented above is the more useful alternative. The need to visualize the different factors involved and their “weight” in the project’s assessment outcome was also underlined during the meeting.

We will of course need to dig a bit deeper into the problematic before knowing for certain what the outcome of the DISA project should look like. Considering that it is a 3-year project including three different specializations and many different studies, we are still at the very beginning of the process. Nonetheless, those first insights should be helpful in strategically planning our first steps within the project.

Walkthrough of MetaVision and Orbit with two nurses from the Uppsala University Hospital

Paper-based forms for the daily documentation of a patient in the intensive care unit

With the DISA kick-off approaching, we have been working hard on acquiring the background knowledge necessary to getting the project started on the right track. In this context, Gerolf, Ida and I were given this week an exciting insight into the functionality and layout of two computerized systems that have recently been or will shortly be introduced at the Uppsala University Hospital, namely MetaVision and Orbit. MetaVision is a clinical information system intended to support patient monitoring in the intensive care unit and during operations. Its implementation started about one year and half ago and is now almost completed. Orbit, on the other hand, is an operation planning system whose implementation process will start at the end of the month at the Uppsala University Children’s Hospital.

Two nurses who have been actively involved in the implementation of, respectively, MetaVision and Orbit, kindly accepted to walk us through the main components of each system. In so doing, they also provided us with essential contextual information which enabled us to develop a more complete understanding of the current and upcoming situation at the University Hospital.

As I had never seen what a patient’s bedside looked like in the intensive care, I was impressed to see the number of devices connected to the patient. However, I was even more taken aback by the multitude of paper sheets that had to be filled in by nurses for each patient every day prior to the implementation of MetaVision. As the system now automatically gathers data from the different devices connected to the patient, the need for manual documentation is estimated to have been reduced of approximately 80%. The remaining 20% encompasses such information as the meals and drinks given to the patient, the activities related to personal hygiene provided by the nurses (hair washing, teeth brushing etc.), the patient’s position (back, right / left side) or the evaluation of the pupils.

In regard with operation planning, it is now handled by means of different physical folders containing waiting lists. Orbit is expected to replace those folders as well as to support the documentation of operations, where it would partly overlap with MetaVision’s functionality. However, as no integration of the two systems is possible at this point, the implementation of Orbit will require for nurses to enter twice certain pieces of information in order for patient data to be complete in both MetaVision and Orbit. This situation can be explained by the different origins behind the implementation of the two systems: MetaVision’s acquisition and implementation process was launched by the Uppsala University Hospital before the Uppsala County Council decided to have Orbit implemented as a measure to guarantee a safer operations planning.