Abstract
Background
Emergency departments (EDs) are complex socio-technical work systems that require staff to manage patients in an environment of fluctuating resources and demands. To better understand the purpose, and pressures and constraints for designing new ED facilities, we developed an abstraction hierarchy model as part of a work domain analysis (WDA) from the cognitive work analysis (CWA) framework. The abstraction hierarchy provides a model of the structure of the ED, encompassing the core objects, processes, and functions relating to key values and the ED’s overall purpose.
Methods
Reviews of relevant national and state policy, guidelines, and protocol documents applicable to care delivery in the ED were used to construct a WDA. The model was validated through focus groups with ED clinicians and subsequently validated using a series of WDA prompts.
Results
The model shows that the ED system exhibits extremely interconnected and complex features. Heavily connected functions introduce vulnerability into the system with function performance determined by resource availability and prioritization, leading to a trade-off between time and safety priorities.
Conclusions
While system processes (e.g., triage, fast-track) support care delivery in ED, this delivery manifests in complex ways due to the personal and disease characteristics of patients and the dynamic state of the ED system. The model identifies system constraints that create tension in care delivery processes (e.g., electronic data entry, computer availability) potentially compromising patient safety.
Application
The model identified aspects of the ED system that could be leveraged to improve ED performance through innovative ED system design.
Keywords
Introduction
The recent COVID-19 pandemic highlights the unique position of emergency departments (EDs) within healthcare systems. These complex socio-technical ecosystems are under continuous pressure to deal efficiently and safely with unpredictable and potentially high-risk patients. Past literature focuses largely on the problems faced by EDs and strategies to improve performance (Austin et al., 2020). While many interventions have improved ED processes, they typically involve incremental adjustments or discrete changes to how EDs operate. In our study hospital, the ED was undergoing a period of expansion, and planned to move to a new purpose-built facility within the next 12 months, offering the opportunity for a comprehensive and innovative approach to improvement. Clinicians and managers sought to understand how the current ED functioned in practice, including the associated constraints, in order to optimize design and implementation of care in the new location. To make recommendations about system design and improvement initiatives, it is crucial that we understand the system’s purpose, functional structure, and physical context that influence how everyday work is performed.
EDs are complex open systems with patients, staff, external professionals (e.g., paramedics, specialist consultants, police), information, and resources moving between ED, the hospital, and the wider community. EDs can be reviewed through a human factors and ergonomics lens to study their complex behaviors (Canham et al., 2018; Farid et al., 2020; Waterson, 2009). Focusing on the EDs subsystem can help identify both problems and opportunities for improvement but factors external to the ED must be taken into account (Naikar et al., 2005). Cognitive work analysis (CWA) is a systems approach used to understand the functional structure of systems or subsystems, providing a set of tools that facilitate detailed understanding of complex socio-technical systems (Naikar, 2016; Stanton et al., 2017; Vincente, 1999). The first phase, work domain analysis (WDA), describes and aids understand of system functions and how they are achieved within system constraints. WDA is therefore well suited to examining work in an ED.
Cognitive Work Analysis
CWA has been applied in many industries (e.g., Bisantz & Burns, 2008; Euerby & Burns, 2014; Naikar et al., 2003; Stanton et al., 2017): to understand everyday work and inform system design with the aim of facilitating the capacity to respond within system constraints to unanticipated events (e.g., spikes in transmittable diseases; Read, Salmon, Lenné, 2016; Read, Salmon, Lenné, et al., 2016). The CWA framework includes five interlinked phases (Jenkins et al., 2007; Naikar, 2016, Stanton et al., 2017; Vincente, 1999). The foundational phase, WDA, is used to describe the system purpose(s), and how the purpose(s) are achieved within the physical constraints of the system (Jenkins et al., 2007; Naikar, 2016, Stanton et al., 2017; Vincente, 1999). Subsequent phases of the CWA focus on what activities are performed and where within the system (control task analysis, ConTA), the strategies the activities can be performed within the system (strategies analysis, STrA), who (humans or technology) can perform them (social organizational cooperation analysis, SOCA), and the different levels of cognition required (worker competencies analysis, WCA; Jenkins et al., 2007; Naikar, 2016, Stanton et al., 2017; Vincente, 1999).
Work Domain Analysis
WDA is used to describe the constraints around everyday work, independent of events and people, in the form of an abstraction hierarchy (Lau et al., 2008, Naikar, 2016; Vincente, 1999). The five levels in the hierarchy provide an overview of system interactions via means-ends links between nodes at each level. Figure 1 presents the five levels of the abstraction hierarchy with the means-ends links (why, what, and how) between the levels (Lau et al., 2008). The top level, “functional purposes,” addresses why the system exists. The second level, “values and priority measures,” includes values and criteria that stakeholders use to answer the question “is the system achieving its purpose?” The third level, “purpose-related functions,” addresses what functions have to be undertaken for the system to achieve its purposes. The fourth level, “object-related functions,” addresses what processes the objects in the system support. The bottom level, “physical objects,” identifies what objects exist and are used within the system.
The five layers of the abstraction hierarchy with the why, what, and how links between the layers (Lau et al., 2008). Note. ED = emergency department.
Interpreting the layers of the abstraction hierarchy top to bottom, or bottom to top results in a means-end (why-what-how) understanding of the system components. That is, why is a function/process carried out, what function/process is carried out, and how is a function/process carried out. The underlying meaning of means-end links changes depending on the level at which the model is entered. For example, a purpose-related function is carried out (i.e., what), using an object-related process (i.e., how) to support a particular value and priority measure (i.e., why). In the ED, an example of a purpose-related function (i.e., what) is to triage patients. In the abstraction hierarchy presented in Figure 2, the function of triage patients is carried out using the object-related processes (i.e., how) of care decision and pathway allocation, and communication. The function of triage patients affords the ED system to minimize length of stay, maximize treatment outcomes, and minimize adverse events.
Simple WDA abstraction hierarchy showing means-ends links associated with triage patients and provide care purpose related functions. Note. WDA = work domain analysis.
WDA has been applied in isolation to understand complexity and help optimize performance in systems such as road transport systems (Cornelissen et al., 2013; Salmon et al., 2007), aviation and air traffic control (Ahlstrom, 2005; Ho & Burns, 2003; Naikar, 1999), and the military (Nguyen, 2002; Stanton & Bessell, 2014). In healthcare, the WDA has been used to understand team interactions in a birthing unit (Ashoori et al., 2014), nurse unit manager decision-making (Effken et al., 2011), and cardiac nursing coordinators performing telephone triage (Burns et al., 2008). Despite the potential benefits of doing so, WDA has not previously been applied to the ED work domain. The aim of this study was to apply CWA, specifically WDA, to develop a model of an ED. The intention was to identify the pressures and constraints that influence everyday work in an ED context and support efforts to optimize ED performance in the new facility. To support this, once validated via subject-matter expert (SME) review, the model was evaluated using WDA prompts (Read, Salmon, Lenné, 2016; Read, Salmon, Lenné, et al., 2016).
Methods
Study Design
We conducted a WDA of the New South Wales (NSW) ED context based on information derived from national- and state-based documents in Australia following Naikar’s (2016) nine-step methodology. Graphical representation was achieved using the CWA software tool developed by the Human Factors Integration-Defense Technology Center (Jenkins et al., 2007). A series of focus groups was then used to validate the model with SMEs from the participating ED, with the model updated following each focus group. A data dictionary of the contents in the abstraction hierarchy was developed to accompany the model.
Scope of analysis
In Australia, healthcare is governed at both state and federal levels, resulting in differences in policy and guidelines between states and territories. The document review draws on policy and guideline documents from the selected state (NSW) as well as national guideline documents where available. The data extracted from the document review were used to inform the initial development of a WDA model that reflected the ED system. A single ED within NSW was selected as a source from which to recruit SMEs for model validation. The study ED is representative of EDs in NSW and was used to define boundaries around the system under analysis, as suggested by Naikar et al. (2005).
Setting
The study hospital ED has two resuscitation bays, 18 acute care beds, a fast-track area with space for one bed and up to six chairs, two consultation rooms, and a “treatment commenced” area containing up to five treatment spaces (a combination of chairs and beds). Approximately half (46.8%) of the community served by the study hospital ED were born overseas, and half (50.3%) speak a language other than English at home (Western Sydney Local Health District, n.d). Figure 3 shows that the utilization of the study ED over the last 10 years is consistent with the utilization of EDs at the broader local health district level (Bureau of Health Information - Healthcare Observer, n.d.).
The number of presentations to the ED by year and quarter. Note. ED = emergency department; LHD = local health district; LHD = local health district.
In Australia, the treatment of individuals with critical/urgent care needs in the ED is overseen by staff/specialists (nurses, medical officers, specialists, administration staff), using a variety of devices and infrastructure with impacting environmental factors. Although the ED is a subsystem within the hospital system, for the purposes of this analysis, care provided by staff/specialists using devices outside of the ED, such as hospital ward staff or ambulance service personnel, was excluded from the analysis.
Data Collection
Document Review
Policy documents, guidelines, protocols and other documents relating to the ED work system that met the following additional criteria were included: (1) are publicly available; (2) discuss or describe (a) how and what performance data is to be collected and reported, (b) how tasks are to be performed in the ED, (c) the role of the ED in providing care, and/or (d) physical objects/resources within the ED; and (3) are relevant to the Australian, and/or NSW public hospital ED context. Publicly available documents relating to the ED work systems, such as policy documents, operating procedures, and guidelines, were reviewed for relevance.
To identify documents, relevant national and NSW state government health department websites as well as the study hospital website were searched using search bars, drop-down menus, and links to find relevant documents for the general concepts of ED and policy (e.g., “policy” or “guideline” or “protocol”). Table 1 shows examples of the types of documents with examples.
Types of Documents and Examples
Note. NSW = New South Wales; LHD = local health district.
Information was extracted by three independent reviewers (EA, RCW, BB) relating to the document’s web address; level of document (i.e., whether the document is published at the national, state, or local health district level); type of document; year of publication; functional purpose (e.g., what has the ED been designed to achieve? What societal laws and conventions does the environment impose on the ED?); values and priority measures (e.g., what criteria can be used to judge whether the ED is achieving its purpose? How are resources allocated?); purpose-related functions (e.g., what are the functions of individuals/teams in the ED? What functions are performed with the physical resources in the ED?); object-related purposes (e.g., what can the physical objects in the ED do or afford? What processes are the physical objects in the ED used for?); and physical objects (e.g., what are the physical objects or physical resources in the ED?).
Analysis
An initial WDA abstraction hierarchy was developed based on the data extracted from the documents reviewed. A data dictionary was developed alongside the abstraction hierarchy (see Appendix 1 for the data dictionary).
Validation
The initial abstraction hierarchy was refined, and content validity established, through a series of focus groups with 17 SMEs, consisting of ED doctors and nurses. Table 2 presents the demographic characteristics of the SMEs.
SME Demographic Information
Note. ED = emergency department; SME = subject-matter expert.
The focus groups were conducted over 4 months. Participants were recruited through the ED leadership team, who were engaged initially via email, followed by a face-to-face presentation on the study proposal. This research complied with the tenets of the Declaration of Helsinki and was approved by the Institutional Review Board at Western Sydney Local Health District (AU RED LNR/18/WMEAD/251). Informed consent was obtained from each participant. Three focus groups were run in a tutorial room within the ED, where staff members who could be spared from clinical practice for a short time were invited to participate. Focus group participation lasted as long as the consenting participant could be spared from their clinical practice (typically 10 to 25 min), and the sessions were captured through notetaking by observers (EA, RCW and a research assistant) and a record of the participants’ contributions to the tasks described below.
Our focus groups began with discussions to understand the levels of the model, and how the components were related to everyday work. SMEs were provided a copy of the initial model (without means-ends links) and the data dictionary (which explained the meaning of each category). Following this, participants were asked to draw lines between the levels connecting the categories to represent how functions in the model were related, according to their knowledge of ED work. Participants were asked to identify if there were any functional purposes, values and priority measures, purpose-related functions, object-related processes, and physical objects missing from the model, or if any of the categories were redundant. The model was updated based on participants’ responses after each focus group session, and the updated model without means-ends links presented to the next focus group for consideration. Disagreements, such as where some participants created means-ends links and others did not, were resolved through examination of the data dictionary and discussion with an SME.
Insights
To assist in evaluating the WDA for insights, Read, Salmon, Lenné, et al. (2016) prompt questions and analysis insights template were used to document insights (Read, Salmon, Lenné, 2016; Read, Salmon, Lenné, et al., 2016). Only prompts associated with the WDA model were used from the CWA prompt questions. Organizational metaphor prompts were also used to prompt discussion and insight generation (Read, Salmon, Lenné, 2016; Read, Salmon, Lenné, et al., 2016). Insights were classified according to the taxonomy outlined in Read, Salmon, Lenné (2016) and Read, Salmon, Lenné, et al. (2016)
Results
ED Abstraction Hierarchy
The ED abstraction hierarchy is presented in Figure 4.
ED abstraction hierarchy. Bold = the critical means-ends links for the node “data reporting and compliance” (see Discussion). Note. ED = emergency department.
Functional purpose
Both the document review and SMEs agreed that the overall purpose of the ED system is to “provide safe and timely emergency care.” However, SMEs also described the ED system as a way to “provide a pathway to In/Out patient care and community services. These two purposes are represented at the top level of the WDA in Figure 4.
Values and priority measures
Eleven values and priority measures were identified. These include values relating to patient outcomes (i.e., “maximize number of successful treatments/outcomes,” “minimize number of fatalities/poor outcomes,” “maximize patient safety,” “minimize adverse events”), the patient experience (i.e., “maximize patient satisfaction”), staff safety and well-being (i.e., “maximize staff safety,” “maximize staff well-being (satisfaction)”), and compliance (i.e., “minimize waiting times,” “minimize length of stay,” “maximize number of patients to be seen,” “maximize compliance”).
Purpose-related functions
Nine purpose-related functions were identified:
“triage patients” is a brief clinical assessment of individuals with a wide variety of conditions of varying urgency and complexity (and age) presenting to the ED. This function is used to manage the queue of patients, facilitates cultural safety for patients, and determines the most appropriate location within the ED (i.e., model of care) for the patient.
“provide care” is the treatment and management (investigations and observations) of patients with a wide variety of conditions of varying urgency and complexity (and age) appropriately (incl. highly complex, resource-intensive patients). The provision of care function coordinates interdisciplinary team approach and different models of care (e.g., Fast-track, Short Stay Unit).
“transfer of care and patient discharge” ensures patients are safe to depart from a clinical and functional perspective for optimal patient throughput. The transfer of care function facilitates access to appropriate post-acute care options and supports the transfer of information during patient care handover. Patient discharge limits the delays that may occur because of requirements to complete the ED departure process. The transfer of care and discharge function preserves ED capacity for emergencies, minimizing hospitalization and representation rates.
“security management (staff and patients)” ensures patient and staff safety, comfort and security, and includes the lawful protection of individuals by security staff and the management of security risks.
“data reporting” is the mandatory submission of data to national registries, including performance on identified national targets and adverse events.
“unit governance” establishes policies and monitors their implementation and compliance. The unit governance function ensures staff have up to date and appropriate skills, fair and equitable rostering, manages demands and workloads, standardizes care, and compliance with legislative requirements and considerations.
“research collaboration and engagement” ensures the continuous improvement of healthcare service delivery through the use of evidence base and research into acute emergency care in collaboration with researchers.
“reputation management” develops and maintains patient and community trust in clinicians and health service organizations, through patient experience in the hospital/ED, identifying and promoting culturally safe care and catering to all community specific needs.
“organizational culture” fosters an environment that supports the health and well-being of staff through equity in staff decisions, effective multi-professional management teams, active participation/inclusion, executive engagement, and provision of whole of hospital resources.
Object-related processes
Fourteen object-related processes were identified and presented in Table 3 (see Appendix 1 for a complete list of processes comprising each object-related process).
Object-Related Processes Identified in the Model
Note. ED = emergency department.
Physical objects
Twelve categories of physical objects were identified and are presented in Table 4 (see Appendix 1 for a complete list of objects comprising each category of physical object).
Physical Objects Identified in the Model
Many means-ends links were identified. For example, the purpose-related function “triage patients” is connected to eight of the 11 value and priority measures including “minimize waiting times” and “maximize patient safety.” The function of triage patients is carried out using six of the 14 object-related processes, including “care decision and pathway allocation,” and “communication.” The function of triage patients affords the ED system to minimize patient’s length of stay, maximize treatment outcomes, and minimize adverse events.
WDA and organizational metaphor prompts
Table 5 provides insights derived from the application of the CWA WDA prompts. Table 6 provides insights derived from the application of the organizational metaphor prompts. It can be seen from Tables 3 and 4 that the prompts drew out key aspects of the work domain that influence performance and achievement of the functional purposes. For example, conflicting measures of time and safety result in compromises between clinical thoroughness and efficiency, with clinicians encouraged to complete a patient’s journey within a set time frame. Furthermore, if clinicians do not comply with the department communication work-arounds, their patients do not receive the care they are prescribed. See Appendix 2 for the completed analysis insights template.
Insights From the CWA WDA Prompts
Note. CWA = cognitive work analysis; WDA = work domain analysis.
Insights From the Organizational Metaphor Prompts
Discussion
We sought to understand the constraints on everyday work imposed by the characteristics of the ED system, independent of people and events, using WDA. The WDA revealed the legislative and societal values that constrain everyday work in EDs. For example, legislative/regulatory requirements and considerations are present at all levels of the model. For instance, the values and priority measures set by state and national governing bodies relate to patient outcomes, the patient experience, staff safety and well-being, and compliance. However, constraints on clinical care processes and organizational processes imposed by the physical resources in the system determine the effectiveness of the ED system in achieving its purpose-related Functions.
For example, the use of means-ends-links and the utility of the abstraction hierarchy can be described with the node “data reporting and compliance” in the purpose-related functions level (Figure 4 with the relevant nodes and links boldfaced). “Data reporting and compliance” is a heavily connected function, which can constrain work performance and create vulnerabilities in complex socio-technical systems. For example, we can see from the model that achieving “data reporting and compliance” is constrained by “data entry/communication technology” (e.g., computers), and “clinical rooms/spaces and equipment” (e.g., consultation rooms). SMEs reported that poor usability of software programs, restricted availability of computers (i.e., that there were not enough and they often have to queue for computers), and limited availability of consultation rooms put pressure on their work, limiting and shaping their work performance. Consequently, the performance of object-related functions lower in the hierarchy that enable the “data reporting and compliance” purpose-related function (such as “clinical and diagnostic assessment,” “care decision and pathway allocation,” “patient management,” “communication,” “audits and reports,” and “unit management and administration”) was adversely influenced. In this way, decisions about the number of computers, the type of software, and the number of consultation rooms in an ED will impact the ED’s capacity to achieve the purpose related function of “data reporting and compliance.
Beginning with a purpose-related function and following the means-end links upwards in the model, we can see, for example, that “data reporting and compliance” (bolded parts of the hierarchy in Figure 4) is connected to the functional purpose of the ED “provide safe and timely emergency care” via all of the values and priority measures, including “minimize waiting times” and “maximize patient safety.” These two value and priority measures highlight a conflict in the functional purpose of the ED, suggesting there will be a trade-off between “minimize waiting times” and “maximize patient safety” to achieve safe and timely care for presenting patients.
The ED WDA model thus highlights a fundamental conflict between the value and priority measures. As shown in Figure 4 both “minimizing waiting times” and “maximizing patient safety” are required (among other things) for achieving the functional purpose of the ED. Yet it is not possible to do both—where safety and time are in conflict, there will be a trade-off between thoroughness and efficiency (Hollnagel, 2017). Such deep-seated conflict can contribute to large variation in performance depending on whether time or safety is emphasized by governing bodies or dictated by increasing patient demand such as seen during the COVID-19 pandemic.
Contributing to such conflict is the variation in how values and priority measures in the ED system are measured. For example, measures of time (e.g., time to treatment, time to leave the ED) are automatically collected by the software system and reported regularly to governing bodies. In contrast, measures of safety are not collected automatically by the software system. Rather, proxy measures of safety such as the number of patients leaving the ED within 4 hr of presentation are used instead. The automatic collection of time measures and the proxy use of time for “safety” creates tension between the goal of timely care and safe care. For example, aspects of safe care that take time such as patient consultation (i.e., thorough assessment, fact checking, informed consent) are not captured by proxy measures of safety (i.e., time). Rather, aspects of safe care are penalized by measures of time, and therefore may not be prioritized as highly as the goal of timely care. Such tensions in conflicting measures then shape decisions about how work is prioritized in ED. We know, for example, through a study of 32 of Australia’s largest public hospitals, that attending to safety in EDs increases wait times for patients, and that managerial emphasis on time as the primary measure of performance is likely to result in reduced focus on interdisciplinary teamwork in the ED (Clay-Williams et al., 2020).
The demands placed on clinical tasks in ED are not stable and do not necessarily operate under routine conditions due to the complex characteristics of both the clinical work environment and demand. The WDA was able to characterize the activities in the ED system by revealing the inherent complexities of the work domain and relations between functions and tasks. In doing so, the WDA can identify barriers to the implementation of innovations in clinical practice. For example, we can use the WDA to identify barriers to the implementation of electronic medical records in ED (Görges et al., 2013; St-Maurice & Burns, 2017; Wang et al., 2018). Using the means-end links in the WDA, we can identify the physical objects required to effectively implement electronic medical records such as computers (i.e., data entry/communication technology). From the model, we see that this function is connected by means-end links to every function in the above level, and all subsequent functions in the levels above in the abstraction hierarchy. This means that decisions about the number of computers available, the maintenance of servers, and the usability of software for electronic medical records use have implications at all levels of the ED system. The WDA forms the foundation for other components of the CWA, which allow us to explore how clinical expertise shapes decision-making, performance variability, and formulate who or what (e.g., technology) carries out the activities.
Design Implications
This study has helped clarify understanding of the relationships between the functions, processes, and objects in an ED. Heavily connected functions such as “data reporting and compliance” and “unit governance” represent a high risk in terms of system performance, as a single point of failure could have a disproportional effect on the ED functional purpose.
Critically, highly connected functions are prime areas for system design interventions. For example, an ED’s ability to achieve “data reporting and compliance” depends fundamentally on the servers (i.e., the hardware and software) on which the clinical documentation programs run. Therefore, interventions that address server fail situations or processes for server maintenance are critical for reducing the time that communication pathways are closed off, and workarounds are needed for managing patients and the department. Independent of people and events, EDs are fragile with their heavily connected functions and reliance on key technologies.
Limitations
The CWA framework contains five phases of description, and the phases are chosen based on the project’s needs. The purpose of our project was to model the ED system, developing visualizations of the complex relationships between system functions and processes. Thus, our model provides the basis for further analysis using the other phases in the CWA framework.
The WDA is primarily a desktop-based task, requiring limited physical or technical resources with data for the analysis collected from the internet. We were able to recruit SMEs from a single ED to review the analysis. It is possible that some of the information provided by SMEs may be specific to the studied hospital; however, the top three levels are likely representative of NSW EDs in general as NSW hospitals run their EDs in a very similar manner due to regulation, standards, and mandated processes. The extent to which the findings can be generalized is not known.
The current study aimed to provide clinicians and managers in our study ED with a better understanding of how their ED functioned in order to optimize design and implementation of care in a new facility. However, a gap exists between the analysis of ED systems and ED system design (Read et al., 2018). The CWA–Design Toolkit has been developed to address this gap and could be used in conjunction with the current abstraction hierarchy to develop new ED design concepts (Read et al., 2018).
Conclusion
This paper provides a description of the ED system, independent of events and actors. Using the WDA, EDs can make sense of the legislative and system constraints that shape everyday clinical work. With this understanding, new models of care can be developed to amplify EDs’ capacity to respond to unexpected events and improve how everyday work is performed. While the model we developed was validated by SMEs from a single ED, the model can be adapted and used by other ED clinical teams based on their own documentation and systems to understand the constraints and boundaries around their clinical practice and inform quality improvement projects.
Key Points
We were able to account for differences in ED system understanding and record data based on diverse expertise from focus groups reporting of everyday work processes
The CWA framework and the WDA allows us to identify constraints that shape everyday work in the ED.
The heavily connected functions in the model identify areas where conflict exists between work priorities such as safety and time, leading to a trade-off between thoroughness and efficiency in work completion.
With these research findings, we can now use the understanding of the constraints in ED everyday work to develop innovative design ideas that leverage discrete aspects of the system to produce larger system improvements.
Footnotes
Appendix 1. Data Dictionary
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To provide safe and timely (effective access to) emergency care for urgent/trauma/unexpected illness and/or injury |
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A liaison between Blacktown Hospital and the community, facilitating access to services and facilities |
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Time to mental health assessment/consultation Time to diagnostic initiation Patient wait times by triage category (NEAT) Time to patient review by triage category Time to pathology test results (wait time) Early streaming in less than 10 min Wait time by triage category Off the stretcher time Time to triage Time to specialty consult/review Time to referral to specialty services Time to transfer of care Data items (triage time, date, category, seen by Dr time and date, seen by a nurse time and date) Triage time to treatment commencement time (by triage category) Time to initiation of treatment (wait time; by triage category: T1 resuscitation, within 2 min; T2 emergency, 80% within 10 min; T3 urgent, 75% within 30 min; T4, semi-urgent, 70% within 60 min; T5 70% within 120 min; by clinician) Time to transfer to an inpatient area/admission Ambulance arrival time to transfer into ED system time (% of patients transferred from ambulance to ED within 30 min) |
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Total length of stay in ED (patient time in ED) by triage category; average/median; 90th percentile; by model of care: ETZ, PECC, MAU (aver, less than 3 hr, LOS in MAU alone, LOS less than 48 hr), FT (less than 2 hr) percent of patients who spent 4 hr or less, percent of mental health patients with an ED LOS less than 8 hr; by index conditions SSU discharged within 24 hr FT discharged within 2 hr (incl. monitoring, observations, interventions, and management plan discharge) Number of occasions of patient breaches of 2 hr target Total number of patients assessed, treated and discharged or admitted within 4 hr (NEAT) Emergency Access Performance (8 hr) Emergency Treatment Performance Triage time to patient discharge time Ambulance arrival time Arrival data (facility code, medical record number, mode of arrival, type of visit, ambulance case number, patient arrival date and time) Departure data items (departure ready date and time, actual departure date and time, mode of separation, referred to on departure information, departure destination) Triage time—time from start to end of triage—should be less than 5 min |
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Number of mental health presentations to ED Number of arrivals by ambulance Rates of Aboriginal and non-Aboriginal patients Number of presentations by triage category Number of people seen within recommended time for triage category NEAT transfer of care (4 hr admission/treatment referral/discharge where clinically appropriate—81% of patients) |
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Number of admissions to hospital from ED by model of care (e.g., fast-track) Number of mental health admissions from ED Number of occasions in which model of care is activated (i.e., number of patients streamed to each model of care) Patient outcomes (e.g., for resus and trauma patients) % treated within recommended times |
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Readmission rate within 28 days of PECC/MAU discharge Number of times trauma response activated and member attendance Number of unplanned representations to ED within 48 hr Patient outcomes (e.g., for resus and trauma patients) |
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Appropriateness of triage category Early clinical decision-making and critical interventions by senior ED physician Number of occasions when flexible plans were activated Number of Did-Not = Waits/Left-at-own-risk Patient incidents Clinical data items (primary diagnosis, additional diagnosis, principal procedure, additional procedure) Patient data (sex, DOB, Country of Birth, Indigenous Origin, language preferred, marital status, address, interpreter service, health insurance status, compensable) Reported incidents, near misses, adverse events, actions taken for example, medication error |
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Current ED capacity by triage category, time of day, day of the week, month of the year Workforce (number of FTE—medical, nursing, support; sick leave rates, turnover rates, vacant positions and time to recruit, completion rate of contracts, staff satisfaction and complaint resolution, clinical support time, accumulation of professional development leave, OHS including nosocomial infections and violent incidents, performance appraisal, staff meetings, structured administration) |
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Risk management (incident monitoring, formal results monitoring) Audit of medical errors Audit of pathology (appropriateness, turnaround time, results checking) Audit of medical imaging (appropriateness, turnaround time, results checking) Audits of Procedural complications (volume or risk clinical conditions, documentation standards, clinical guideline compliance, consultant sign off, time critical interventions, time to analgesia, written discharge instructions, unplanned returns to ED, patient ID, and procedure checking) |
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| With procedures and legislative/regulatory frameworks Equipment considerations (maintenance and replacement, access) Financial considerations (departmental budget, business plan) Regular audits (waiting times, mortality, trauma, complaints, patient satisfaction, clinical practice guideline compliance variance) Clinical audits (hand hygiene, antibiotic stewardship, blood and blood-product use, pressure injury assessment, preventing falls, recognition of deteriorating patient) System derived audit data (number of times changed: arrival time, triage time, triage category, time seen by a Dr, departure ready time, actual ready time, compliance status) |
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Patient satisfaction (happy with level of care) Patient experience (enhancing/traumatizing experience) Patient access to care and care option Patient complaints |
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Staff satisfaction and feedback Staff participation in committees and professional bodies Partnering with consumers (involvement with consumers in improvement activities, active approach to person-centered care) |
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Assess/triage people who present with a wide variety of conditions of varying urgency and complexity (and age) presenting to the ED Early allocation to appropriate model of care (aka streaming) Promote quick triage Reduce queuing |
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Multiple ED models of care: fast-track, short stay unit, EMU, MAU Reduce unproductive waiting periods Early/timely treatment and risk stratification (incl. antibiotics, pain relief and other symptom management) Timely access to safe and quality ED care Rapid transfer to definitive intervention Provide time critical lifesaving interventions Ensure minor injuries/illnesses are treated efficiently Provide primary care to nonacute ambulatory patients Ensure the right/appropriate treatment is provided within an appropriate time frame for every patient (effective time frame) Treat patients with a wide variety of conditions of varying urgency and complexity (and age) Manage (investigations and observations patients with a wide variety of conditions of varying urgency and complexity (and age) appropriately (incl. highly complex, resource intensive patients) Provide safe, effective, high-quality care For all ages, 24 hr a day, 7 days a week Continuous clinical management of people in ED (incl. the waiting room) To care for patients including major trauma, elderly, children and adolescents, patients with physical and mental disabilities, victims of child abuse, domestic violence, or sexual assault, patients with mental health issues, patients with infectious diseases or who are immunocompromised, custodial patients, patients affected by chemical, biological or radiological contaminants Coordinate interdisciplinary team approach to patient care Confidential, supportive, and understanding attitude to patient care and needs Limit redundant assessments or treatments Nursing Roles: Nurse Practitioner, Clinical initiatives nurse, RN, Nurse Educators, Clinical Nurse Consultant, Nursing Unit Manager Allied Health Staff (Physio, Pharmacist) |
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Registration of patients Ensure patients are safe for departure from a clinical and functional perspective Facilitate access to appropriate post-acute care options Ensure optimal patient throughput Effective pediatric networking arrangements across the AHS Early identification of patients appropriate for management in models of care outside ED—ensuring patients are treated in the most appropriate setting Support the transfer of information during patient care handover Acute care initiating, assessing, performing and transferring care of patients who are acute, unstable, and complex (e.g., cardiac monitoring, frequent observations, specialized interventions, higher level care, comprehensive management plan) Facilitate and advocate access to available care and support services Ensure minor injuries and illnesses are discharged efficiently Limit the delays which may occur because of requirements to complete the ED departure process Reduce/minimize hospitalization and representation rates of people aged 70+ years, of indigenous peoples aged 50+ years Collaborate with health care providers Preserve ED capacity for emergencies Disaster management Coordinate with external stakeholders to ensure locations outside ED for appropriate short stay admission |
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Security risk management Patient comfort Patient safety and security Staff safety and security Lawful protection of people by security staff |
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Submission of data to national registries (weekly or monthly) Minimize/recognize harm Risk identification and management in the clinical environment Monitoring mechanisms for clinical safety and quality Meet performance targets for quality and efficient health care service Compliance with legislative requirements and considerations Clinical space and patient flow |
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Improve the quality of care received by patients Address gaps in the existing health care service Facilitate patient care and flow Improve clinical outcomes Manage demands and workload Capacity to deal with changing levels of demand Standardizing care Ensure staff have up-to-date and appropriate skills Ensure staff have capacity/skills to appropriately manage patients Staff satisfaction and morale Appropriate/best practice/fair and equitable rostering Teaching of acute emergency care Maintain an appropriately skilled workforce Organized and coordinated management of ED business to improve the working environment Workforce and service planning Organizational productivity, performance, and efficiency Support the productivity and sustainability of the health system Delivering better value health care Efficient staff deployment and management Maintain an appropriately resourced workforce to match growth Rostering processes for generation, publication, maintenance, payroll, adjustments, and availability of staff Realign staff roles and resources to establish models of care |
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Collaborate with researchers Continuous improvement of healthcare service delivery Research into acute emergency care Use of evidence base |
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Improve/ensure/provide equitable access to care Cater for all community specific needs Develop and maintain patient and community trust in clinicians and health service organizations Promote and maintain the hospitals reputation Patient experience in the hospital/ED Identify and promote cultural safety for patients |
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Staff attitude Promote healthy workplace Health and well-being fostering an environment that supports the health and well-being of staff Staff well-being Equity in staffing decisions Support an inclusive and fair culture Effective multi-professional management team Executive engagement Active participation in whole of organization improvement activities Promote and provide whole of hospital resources |
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Patient transfer internally/externally Transfer of patient care Patient transfer Processes for discharge planning and referral Admission and discharge (to ward, assessment unit, short stay unit, mortuary, transit lounge, home) Establish arrangements with external service providers to address needs of patients requiring services after the streaming process Guidance for dealing with patients that arrive with other services staff such as police Guidance on how to deal with disasters Optimize ambulance patient delivery processing Reception of patients and visitors Creating admission paperwork Admission processes |
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Access to rapid diagnostic investigations (ordering and reviewing/interpretation, pathology, radiology, other tests) Align diagnostic services to support team decision-making and improve timely access to diagnostic services (turnaround time for results) Appropriate diagnostic test ordering (incl. cost effective, ethical, evidence-based manner) Primary survey (incl. resus and time critical interventions, airway and oxygenation, breathing and ventilation, circulation, neurological assessment, focused assessment, and monitoring for changing parameters and complications) Assess and manage patient as per trauma policy and procedure Rapid assessment process (by triage or CIN) Mental health self-harm risk assessment and management Assessment of premorbid function Assess minor eye injuries Medical and nursing assessment Identified risk factors Specialist/Dr clinical/physical assessment (incl. movement, cognitive/visual impairment) Disability assessment Provide information about the patient experience (pain control, condition, treatment) |
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Early diagnosis decision-making by senior ED MO High-quality rapid decision-making Clinical decision-making Collaboration with specialty services to expedite care Specialty team consultation Allocation of patients to appropriate area or stream within the ED Triage (determination of patient acuity and level of urgency, basic first aid, and referral to most appropriate area for treatment) Senior assessment and streaming (early diagnosis, clinical management plan development, and disposition decisions for patients) Patient streamed to appropriate care area (other: GP, outpatients, home, other hospital) Disposition to operating theater |
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Activation of trauma code crimson (surgical consultant, relevant subspecialty, radiographer, include. Informing blood bank—massive transfusion protocol) Internal transport Acute care (principles and processes that promote efficiency in initiating, assessing, performing and transferring the care of patients who are acute, potentially unstable, and complex) Treatment of major and minor trauma cases and medical emergencies Resuscitation (trauma management) Participate in the assessment and management of patient’s subject to MET calls Life support airways/breathing/circulation Intubation and airway management Deal with adverse events (incl. the WR) Acute pain management Cardiovascular therapies Musculoskeletal care (management and relocation of fractures/dislocation and plastering) Application of plasters/splints/other procedures Wound treatment (minor: abscesses, septic, hands, eye injuries, ear, nose and throat complaints, minor fractures) Provision of first aid Wound care (incl. suturing and dressing management) |
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Medication administration and supply |
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Care plan/coordination development Coordinate patient care using clinical pathways (e.g., chest pain pathway, sepsis pathway) Treatment and disposition Optimum diagnosis and individual treatment planning for each patient Treatment commencement and completion Commence clinical management plan Adjunctive diagnostic treatment and admission/discharge services (Medical imaging, allied health—physio, OT, community interface team) Reduction in process/procedure duplication Comprehensive care planning and delivery Standardizing care to reduce variation for conditions (such as chest pain) Patient management (incl. cardiac, vital signs, observations) and evaluation Assess the needs of older people (incl. the environment) at regular intervals Ongoing assessment Regular assessment Management and treatment of patients queuing in the ED WR Ongoing monitor and review of patients Provision of basic patient care Clinical procedures Patient information collection Patient information documentation Document procedures Informed consent Data collection for patient registration and record keeping Collating accurate medical records (incl. creating and printing necessary paperwork) Electronic recording of patient information |
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Targeted/ongoing communication between staff and or to patients and their carers Communication between ED and inpatient units Communication of visiting medical officer or staff specialist Ambulance services Processes for communicating with care givers and community providers Standardized communication between prehospital personnel and hospital personnel Handover Transfer of information/accountability/responsibility for patients between clinicians Teamwork Call for help Patient participation in decision-making related to health management and always treated with dignity and respect Provide information in a culturally and linguistically appropriate way (incl. referral to support/community services) Communication with patients on care plan Communication with children (as patients) and their families (incl. strategies to support verbal information) Patient education (assist in self-diagnosis and care after discharge) Patient-focused model |
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Decontamination of patients who present with toxic and/or infectious substances Preparation of patient environment Housekeeping Bed cleaning |
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Data reports (incl. HR reports, sick leave, retention rates, vacancy, violence, and aggression statistics, OH report) Analysis and information management (incl. clinical data capturing and reporting, advanced computer literacy) Documentation of presentation, assessment, treatment, and follow-up including time and date information Monitor compliance with data collection and submission Monitoring the depts progress toward reporting requirements/coordinate data collection |
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Regular morbidity and mortality meetings Risk assessment, identification, and mitigation (patient safety) Prevention of patients leaving before treatment |
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Equip and organize bed areas/bays using lean thinking principles Functional bed capacity Capacity to treat bariatric patients Rostering for appropriate skill and experience mix (incl. governance structures to oversee roster planning, creation, approval, monitoring, and reporting) Baseline skill mix (combination of qualified and experienced medical and nursing staff, allied health) Optimizing the use of permanent, casual, and supplementary workforce Fair and equitable rostering Appropriate management of fatigue Shift changes Recruitment to fill staff gaps Adequate staff supervision Available staff Limit the responsibilities and additional tasks required by particular roles Patient privacy Legal policy and LHD obligations and applications National accreditation Development and revision of policy Compliance with drug storage and use regulations Auditing Conform to regulatory framework Review of policies, procedures, protocols, audits, and system evaluation reports. Communicating organizational risk management information Accreditation and legislative obligations Administration support—clerical and data management Support processes and routine follow-up by management Complex leadership Clinical leadership Clinical management Managing patient IT systems/managing patient IT system skills (incl. data entry, medical terminology) Budget Internal review of incidents relating to departure of patients Preparation of staff environment |
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Conduct training to improve competencies and performance outcomes Supernumerary support Maintain and update skills Staff access to ongoing professional and clinical education opportunities Provide education to health workforce Continuing professional development of their own staff Problem-solving skills and experience Skills and knowledge to make referrals to other health professionals Clinical expertise in Triage to determine patient’s clinical urgency Knowledge/understanding of patient confidentiality Knowledge of hospital geography and systems and community services Clinical proficiency Recognize signs of deteriorating patient |
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Protect children from stressful situations (exposure to adult patients) Safe entry and exit Low stress environment Provide a calm atmosphere Fitting and provision of mobility aids (e.g., crutches) Substituting hazards with lesser risk Minimizing risk by engineering/admin means Security |
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IT personnel Volunteers Adjunctive services (admin and services) Cleaning and maintenance staff Security personnel Admin staff Researchers Students Teaching staff Pastoral care staff Orderlies Disability carers Respite carers Liaison staff Onsite and visiting clinical staff |
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Visibility—from the triage area Colocation of clerical registration and triage Children’s play equipment Separate children’s waiting area Public address system Waiting areas to be uncluttered, well lit, unbroken visual area Seating—different colored, comfortable, robust, and easy to clean Wayfinding aids in appropriate languages Access to toilets Potentially aboriginal art or other cultural aids CCTV on entry Reception and interview rooms Two doors for triage Duress alarms (fixed/mobile) Controlled entry to clinical rooms (card access) Information on ED processes—brochures or audiovisual aids Signage and directions—clear, multilingual, fit for purpose Information kiosk Public health information Vending machines Information about ED alternatives Hearing loop system Water General light and power Fire alarms Entertainment system Alcohol based hand rub Clocks |
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Access to interpreter service Culturally appropriate information (regarding triage, the waiting room process) Signage (clear, multilingual) Wayfinding aids in appropriate language(s) Telemedicine enablers Seating—high-backed high-level chairs Wheelchairs Nurse call system Blanket warmer Warm humidifiers Appropriate mattresses for pressure care Ice machine or access to one Linen/pediatric linen Mobility aids (wheelchairs, crutches) Clothing Disposable nappies Access to pressure relieving mattresses Patient surveys Mechanical high-low beds Benches Suspension devices for terminals Patient slide and other manual handling devices |
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Collation of medical records Printing ID labels General inquiries Adult and pediatric ED observation chart Adult and pediatric ED medication chart Trial of fluids chart Falls screen Mental state sensory summary Current levels of activity and instrumental activities measures including nutritional status Social/cultural functioning-carer Departure and discharge from ED checklist Healthcare records Appropriate documentation forms (adults and pediatrics) Clinical resources Toolkits Clinical pathways Incident information management system—reporting management of all incidents Variance reports Stocktaking Equipment requests Infrastructure and equipment requirements Clear diagnostic and management pathways Security documentation Admin/clerical equipment Clinical pathways and protocols Treatment protocols (incl. standing order protocols to manage conditions such as sprains, strains, minor wound management, tetanus prophylaxis, analgesia) Clinical practice protocols Departure and discharge from ED checklist Letters—discharge letter including details about diagnostic tests and treatments, authority to leave Factsheets, Verbal Notification of parent/carer on transfer Patient surveys |
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Diagnostic test protocols Pathology request forms Patient factsheets Point of care testing Bladder scanner Portable examination light Manual sphygmomanometer Urine analysis machine Transport defibrillator Thigh sized blood pressure cuff Mobile equipment (x-ray, ultrasound, CT trolleys for clinical procedures) Charging facilities/recharging equipment Blood glucose monitoring machine Peripheral devices Device to measure intra-ocular pressure Slit lamp and visual acuity chart Ophthalmoscopes Sigmoidoscope Glasgow coma scale/pediatric Glasgow coma measure |
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Computer (workstation) on wheels or fixed Associated software, drives, printers, intranet access Internet/Wi-Fi network Telephone communications system Wireless cabling and outlets Staff call panel Dedicated direct phoneline for referring medical practitioners Phone Cordless/mobile/portable handset phone Duress alarms (fixed/mobile) Location finding duress alarm systems Pager Departmental voice communication telephones Data point to patients’ bedside Physiological monitor networking Public telephones Nurse call system Patient status alarm Overhead pager systems and intercom Pager infrastructure Public address system Pens Paper Other stationary |
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Cardiac monitor Defibrillator Glucometer Broselow tape Hands free defibrillator with external pacing capabilities (per bed) Fiberoptic laryngoscope handles and blades IV fluid warmer machine Gas humidifier Forced air blanket warmer Wall suction (per bed space) Physiological monitoring equipment (ECG, SpO2 NIBP, invasive monitoring, core temperature, capnography; per bed) Trauma trolley (per bed space) Access to 24 hr blood gas analyzer Femur splint Syringe driver x2 per resus bed Difficult intubation options (fiberoptic intubation stylet, flextip laryngoscope blade, surgical airway equipment) Adult Entonox wall supply (per bed space) Tidal volume spirometer Crash cart Oscillometric sphygmomanometer (dynamap) Manual sphygmomanometer Adhesive tapes Intraosseous needle Three-way tap Extension tubing Burette Intravenous solutions Intravenous infusion pump Indwelling urinary catheter Arm boards (parker baby boards IV giving set Needleless T piece extension tubing Pathology tubes Syringes |
Bougie/stylet Medical air outlet General power outlet Nitrous oxide with scavenging unit Nebulizer mask Oxygen tubing Oxygen outlet Stethoscope pulse oximeter with pleth Oximeter tape volume spacer mask Oxygen head box Nonrebreather oxygen mask Self-inflating resus bags pH paper Oxygen mask (Hudson) Nasal prongs Cervical collar Nasogastric tube Magill forceps Tape Suction tube Catheter and devices Y suction catheters Laryngoscope Laryngeal mask ETT Introducer Nasopharyngeal airway Oropharyngeal rigid sucker Disposable oropharyngeal airway Mechanical ventilator for each resus bed Bedside ultrasound machine Otoscope/ophthalmoscope (each bed space) NIV machine 1–2 (bipap/Cpap) Ketone monitor Glucometer × 1 per 3 beds Resuscitation area neonates to adults Transparent siliconresus masks Amethocaine 4%, tourniquet Antimicrobial swipes Cannula Endotracheal tubes |
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Patient examination area Australasian Triage Scale Triage space Triage trained nurses Desk Chairs Examination couch Examination trolley Weight scales (including infant scales) Spirometer × 1 Vital signs machine × 1 Otoscope/ophthalmoscope Glucometer × 1 ECG machine Patient history demographic measures |
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Acute area space Glucometer × 1 per 6 beds Ophthalmoscope per bed Wall suction per bed space Physiological monitoring equipment (ECG, SpO2 NIBP) with central monitoring system Vital signs machine × 1 per 4 beds Thermometer × 1 per 4 beds ECG machine × 1 per 4 beds Low pressure suction device |
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Subacute area space (including fast-track) Glucometer × 1 per 10 beds Vital signs machine × 1 per 4 beds Thermometer × 1 per 4 beds Portable doppler machine (fetal, vascular) Portable oximeter machine Portable PV light source Portable ENT light source Head lamp Slit lamp Plastering equipment Splinting/supportive bandages Plaster remover equipment (saw, spreaders) Electric ring cutter, otoscope/ophthalmoscope (per bed space) Wall suction at each bed Breast pump Access to pneumatic tourniquet (biers block machine) Adult Entonox cylinder (wall supply in procedure room) Manual portable sphygmomanometer ECG machine Tenometer Dental kit |
Fast-track: Fast-track space Waiting chairs Individual assessment/treatment bays Eye room/procedure room Staff station Utility room Computer work stations (COWs) and associated software Reclining treatment chair equipment for commencing treatment Trained staff Basic assessment equipment |
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Internal waiting room space Assessment rooms Consultation rooms Procedure rooms Treatments rooms Isolation rooms Single rooms/cubicles Interventional radiography suit Hybrid angiography suite or computed tomography Disaster equipment |
Trolley/emergency trolley Ventilation Pneumatic tubes and automated trolley systems Procedures trolley First aid equipment IV pump × 1 per bed space Extra feeding pump × 1 Syringe drivers as required for infusions Localized flow chards Neuro torch |
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Separate area for psychiatric emergency center services 24/7 staff presence 4–6 bed inpatient unit bed capacity |
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Infant resuscitaire Broselow tape Electric intra osseous access device Axillary thermometer Patient warming device (e.g., overhead warmer) Pediatric vein transilluminator Pressure controlled IV pump device × 3 Neonatal ventilator Headbox oxygen Mixture of trauma beds and cots Bubble CPAP Pediatric safe bed Disposable nappies |
Diversion/entertainment equipment: TV/DVD player Computer games Distraction box Continuous oxygen saturation monitor with wave form Infant scales Nitrous oxide blender Pediatric trained nurse Surgical airway equipment Clocks Lighting Pediatric cot/bed with rails insitu |
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Clinical area/space large enough for 2 chairs and a bed, private with 2 exits, close to WR and T Bed, recliner, or chair for patient assessment IV access and pathology collection equipment Handwashing facilities Qualified CIN staff Vital signs monitor with pulse oximeter First-aid equipment, bandages, ice packs, simple dressings and wound equipment, slings, splints Simple analgesics, topical preparations (e.g., laceraine/- emla/angel, rehydration solutions Uninterruptable power supply Adult and pediatric ED observation chart Adult and pediatric ED medication chart |
Bariatric capable objects (Furniture, Toilets, Beds, Scales, Hoist, Specialist equipment, trauma bed, wheelchair) Patient lifter to 300 kg Patient scales to 300 kg Bedside commode to 300 kg |
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Requirements for developing, approving, publishing, distributing, monitoring, reviewing, rescinding, and transferring responsibility for policy documents Information about local procedures, processes, and nuances Policy and procedure documents Routine admission procedures Pediatric admission procedures Clinical practice guidelines Documented operation procedures, policies, arrangements Policy, procedures, and protocols addressing standards and processes for managing healthcare records Antidiscrimination policies and procedures Inclusion and exclusion criteria for the different models of care, for diagnostic tests and treatment Privacy principles legislation Currency on accredited adult and pediatric advanced life support courses Policy compliance Work health and safety legislation Industrial awards Service agreements between ambulance and LHD/SHNs Audit documents Quality improvement and accreditation processes/requirements Clinical governance arrangements Security documentation Daily physical inspections Reporting lines during emergencies Processes for recovery and returning services to normal following an emergency Nurse call system Patient emergency system Standardized handover process Point of care clinical systems |
Guideline education Rostering system (rostering capability framework, rostering best practice program Orientation booklet/DVD Certificates Appraisals Documentation of research, grant, media, project reports, presentations, publications Workforce requirements Supervision Scope of practice Incident information management system—reporting management of all incidents Staff skills/competencies (fast and safe decisions about treatment, investigations, discharge, plastering, suturing, cannulation, venepuncture) Job descriptions Records of participation/attendance registers for in-services Staff timetable/roster Meeting minutes/agenda Staff surveys Specialist nursing skills Comprehensive triage training and assessment program OH&S training and understanding Aggression management and de-escalation skills/training The emergency triage education kit Between the flags, DETECT and DETECT Jnr NDEC mapped core skills review materials Inclusion and exclusion criteria for the different models of care, for diagnostic tests and treatment Supervision First-line care courses |
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After-hours access and remote security CCTV (surveillance) Physical and symbolic barriers Single entry point Security access control Fire indicator panel Uninterruptable power supply Airconditioning Heating Temperature control system Well-lit, uncluttered spaces Environmental considerations (acoustics, lighting, privacy, décor, signage, ergonomics, access and mobility, safety, and security) |
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Patient meals—age appropriate Patient kitchen Tea/coffee making facilities Bread and butter Baby formula preparation facilities Infant formula Water Vending machines |
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Decontamination shower—flexible water hose. Floor drain, contaminated water trap Decontamination packs Personal protective equipment—bay and equipment Decontamination equipment Spill kit Alcohol-based hand rub Handwashing facilities Toilets—high level adapters for toilet seats, pediatric toilets Baby change facilities Alcohol-based hand rub Handwashing facilities Waste management equipment Bins Cleaners |
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Lockable cupboard/room/fridge Drugs Documentation system Administration equipment (e.g., oral use only medication syringes) Standing orders for the supply of medications Clinical consumables: Oral rehydration solution (hydrolyte) |
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Meeting rooms Offices Staff kitchen/tea room/staff room Staff lockers Storage Store room Staff station Write up space |
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Appendix 2. Completed Analysis Insights Template
| Insight No. | Describe the Insight | Type of Insight (Assumption, Leverage Point, Metaphor, Scenario Feature, Pain Point, Design Solution) | How Did It Arise? (Phase of Analysis, Thought Process) | Date of Documentation | Who Was Involved in Developing the Insight? | How Could It Be Incorporated in the Design Process? |
|---|---|---|---|---|---|---|
| 1 | There were two purposes specified in the system. The potential conflict between these purposes would occur in circumstances where the access to in patient care is blocked due to limited/no beds available. | Scenario feature | Thought process | July 2019 | EA, RCW BB | By designing and integrating processes that serve both functions, rather than one function. |
| 2 | Values and priority measures for time are in conflict with safety measures—likely resulting in a trade-off between thoroughness and efficiency. | Pain point | Abstraction hierarchy development | June 2019 | EA, RCW BB | Designing automated data collection to ensure both are collected equally. |
| 3 | Some values and priority measures are not consistently measured such as patient satisfaction, or staff well-being/satisfaction | Leverage point | Data collection | August 2019 | EA, RCW BB | Designing and creating measures that can be automatically collected. |
| 4 | Patient registration and clinical documentation, data entry/communication technology, and clinical rooms/spaces and equipment support the most object-related processes | Pain point | Data collection | July 2019 | EA, RCW BB | Designs need to ensure adequate and fit-for-purpose resources are available. In addition, processes for maintenance of resources need to be effective. |
| 5 | Clinicians who use the software for communicating patient needs and status are punished for compliance (i.e., nothing gets done for their patients). Engaging with work arounds are rewarded. | Leverage point | Data collection | July 2019 | EA, RCW BB | Designing communication systems that are accessible, fit the work processes and the way humans communicate. |
| 6 | How can the system identify a breakdown when it is just starting and provide assistance while maintaining other functions? | Leverage point | Thought process | January 2020 | EA, RCW BB | Designing a software program that automatically identifies potential weak points in the system, such as poor skill mix and potential fatigue to support resource allocation and breakdown strategy planning. |
| 7 | How can we change the burden of documentation on clinicians? | Leverage point | Abstraction hierarchy development | May 2019 | EA, RCW BB | Designing more intuitive software programs, create more opportunities for documentation to happen as they work. |
| 8 | Clinicians are punished for thoroughness in assessment and treatment | Pain point | Abstraction hierarchy development | May 2019 | EA, RCW BB | Designing systems and processes that reduce wasted time to create time for assessment and treatment. |
| 9 | How can the system identify available resources (i.e., hospital ward beds) when the ED is approaching capacity and provide assistance? | Leverage point | Thought process | January 2020 | EA, RCW BB | Designing and integrating a hospital wide a monitoring system that flags system congestion without the need for manual reporting of status. |
Acknowledgments
All authors are employed by Macquarie University or University of the Sunshine Coast, and their research and authorship of this article was completed within the scope of their employment with Macquarie University or University of the Sunshine Coast.
Author Biographies
Elizabeth Austin is a Postdoctoral Research Fellow in the Human Factors and Resilience Team in the Australian Institute of Health Innovation and uses social psychology theories and human factors methods to better understand human behaviour in the work environment. She guest lectures at Macquarie University.
Brette Blakely worked as a researcher for over 4 years with Australian Institute of Health Innovation before moving to the Department of Philosophy at Macquarie University. Brette Blakely combines ethical and scientific perspectives to the provision of complex health care and research issues.
Paul Salmon holds a chair in Human Factors and is creator and director of the Centre for Human Factors and Sociotechnical Systems at the University of the Sunshine Coast. He currently holds an Australian Research Council Future Fellowship and has over 20 years experience in applied Human Factors research in a number of areas, including defence, transportation, workplace safety, sport and outdoor recreation, cyber security, and disaster management.
Jeffrey Braithwaite is Professor of Health Systems Research and the Founding Director of the Australian Institute of Health Innovation. His research examines the changing nature of health systems, with his key expertise in quality of care, patient safety, systems improvement, and implementation science. He has contributed over 640 refereed publications and has presented at international and national conferences on more than 1,020 occasions, including over 110 keynote addresses.
Robyn Clay-Williams is an internationally regarded health services researcher and a leading exponent of Resilient Health Care. Robyn leads a research stream at the Australian Institute of Health and Innovation, Macquarie University, in the field of human factors and resilience in health care. Her expertise is in creating health systems that can function effectively in the presence of complexity and uncertainty.