Patient Handoffs: A Cognitive Systems Engineering Perspective

1. Patient Handoffs: A Cognitive Systems Engineering Perspective November 11, 2011

2. What is cognitive systems engineering? Human Factors (‘50):interdisciplinary human-centered approach to addressing design challenges Cognitive Systems Engineering (‘80):engineering a system of human and machine agents performing cognitive tasks in a domain

3. Cognitive Systems Engineering is... Coping with Complexity • situations • scenarios • tasks • domains In challenging: • expertise • knowledge • strategies With experts: • artifacts • other agents Supported by: Cognitive Triad

4. …In The Era of Complexity New Communication Formats Augmented Cognitive Capacity Integrated Capabilities

5. How Did NASA do Handoffs?

6. NASA: Handoffs Help to Recognize Unexpected Events …making sure they correctly interpret nominal situations as being nominal, and recognize early in the game off-nominal signatures …The handover's critical … in how they have correctly detected and communicated the situational status* *TandiBagian, e-mail, January 31, 2000

7. Potential Lessons for Patient Handoffs Communicate whether an event is expected or unexpected Include degree of diagnostic uncertainty Provide evidence for diagnostic judgments to allow errors to be detected Be receptive to having reasoning challenged

8. NASA: Handoffs are Given to Someone Who Already Knows a Lot Along with having a base of knowledge [from working the day before], the incoming folks likely have seen the anomaly/fault log, the events that [NASA] is currently tracking, have been listening to the loops or watching [NASA TV]* *TandiBagian, e-mail, January 31, 2000

9. Potential Lessons for Patient Handoffs Distinguish between novel and ‘handback’ information For handback information: Emphasize what has happened since the person was last directly responsible and who will do pending actions Expect active engagement from person accepting handoff

10. NASA: Handoffs are ‘Bottom Line’ and Details on Demand Folks are mentored to understand that handovers are to be efficient, pass along what needs to be understood, verify correct situational awareness …it's a real skill that comes hard to some folks who would naturally try to provide details and descriptions, rather than primarily the bottom line.* *TandiBagian, e-mail, January 31, 2000

11. Potential Lessons for Patient Handoffs Emphasize synthesis and interpretation Use ‘on the job’ coaching to minimize details and descriptions Minimize social elements during handoff Triage ‘most important first’ in case handoff is cut short

12. Summary of CSE Perspective on Handoff Opportunities • Efficiency could be increased by: • Reducing handback information • Coaching on ‘bottom line’ interpretation and synthesis skill • Providing details on demand • System resilience could be increased with: • Faster responses to unexpected events • Detecting erroneous situation assessments • Clarifying responsibility for pending actions

13. Thank you for your attention Partial funding provided by the 2010-2011 Hospira Research Grant of the National Patient Safety Foundation