Using Human Factors and Systems Engineering to Evaluate Readmission after Complex Surgery

Abstract

OBJECTIVE To utilize a human factors and systems engineering approach to understand contributors to surgical readmissions from a patient and provider perspective. BACKGROUND Prior studies on readmission neglect the patient perspective. To address this gap and to better inform intervention design, we evaluated how transitions of care relate to and influence readmission from the patient and clinician perspective using the Systems Engineering Initiative for Patient Safety (SEIPS) model. METHODS Patients readmitted within 30 days of discharge following complex abdominal surgery were interviewed. A focus group of inpatient clinician providers was conducted. Questions were guided by the SEIPS framework and content analyzed. Data were collected concurrently from the medical record for a mixed-methods approach. RESULTS Readmission occurred at a median 8 days (range, 1–25) following discharge. All patients had follow-up scheduled with their surgeon, but readmission occurred prior to this in 72% of patients. Primary readmission diagnoses included infection, gastrointestinal complications, and dehydration. Patients (n=18) and clinician providers (n=6) identified a number of factors during the transition of care that may have contributed to readmission, including poor patient and caregiver understanding; inadequate discharge preparation for home care; insufficient educational process and materials, negatively impacted by electronic health record design; and inadequate care team communication. CONCLUSIONS This is the first study to utilize a human factors and systems engineering approach to evaluate the impact of the quality of the transition of care and its influence on readmission from the patient and clinician perspective. Important targets for future interventions include enhancing the discharge process, improving education materials, and increasing care team coordination, with the overarching theme that improved patient and caregiver understanding and engagement are essential to decrease readmission and post-discharge health care utilization.

Early Rehospitalization After Prolonged Intensive Care Unit Stay Post Cardiac Surgery: Outcomes and Modifiable Risk Factors

“…With minimal access to physician services, it stands to reason that ongoing management of manageable comorbidities would degrade, resulting in rehospitalization. Our findings are corroborated by others who have also found that patients with lower education levels, lower income, and increased distance from the hospital/rural location had a higher risk of rehospitalization, though the patient population studied was different from ours . These hypothesis‐generating findings need corroboration with prospective study to determine whether manipulating these variables affects outcomes.…”

“…Our findings are corroborated by others who have also found that patients with lower education levels, lower income, and increased distance from the hospital/rural location had a higher risk of rehospitalization, though the patient population studied was different from ours. 9,21,25,29,31,43 These hypothesis-generating findings need corroboration with prospective study to determine whether manipulating these variables affects outcomes. If indeed psychosocial and physician access postdischarge are major obstacles for patients and the only viable option for the patient becomes repeated inpatient treatment, then perhaps this would need to be accounted for before hospitals (in the United States) are financially penalized for rehospitalization.…”

Sustainability of protocolized handover of pediatric cardiac surgery patients to the intensive care unit

“…Nevertheless, it is widely accepted that data‐driven process improvements alone cannot lead to sustained changes in safety culture, as those improvements do not account for biases created by human factors. Multifaceted interventions that bundle standardization of care process with organizational changes that take into account human factors are often necessary to sustain changes in culture safety .…”

Creating a culture of communication in undergraduate medical education

“…However, we now know that quality communication leads to measurable improved outcomes across a wide variety of health care metrics, including increased patient satisfaction and adherence to medication, enhanced trust in a clinician, 1,2 improved outcomes in a large selection of chronic diseases, [3][4][5][6][7][8] and reduced costs for diagnostic testing and end-of-life care. 9,10 Conversely, studies demonstrate that failures in communication are associated with increased medical errors, [11][12][13] higher readmission rates, 14 decreased outpatient follow-up, 15 and increased malpractice claims. [16][17][18] The Institute of Medicine identified two communication-heavy attributes, patient-centered care…”