KATHERINE JONES
Clinical Provider Testing Behavior at Michigan Medicine
This project is the result of a partnership between the Division of Quality Health Improvement (DQHI) in the Michigan Medicine Pathology Department and the University of Michigan Stamps School of Art & Design, Masters of Design (MDes) in Integrative Design program. I co-designed alongside a cohort of five Master's students over the course of a four month semester during
the winter of 2018.
Problem
Approach
Observations
& Interviews
Synthesis
Outcome
Conclusion
Our objective was to investigate unnecessary test utilization (inappropriate testing) in acute care settings at Michigan Medicine. Research shows inappropriate testing occurs due to a variety of factors including “defensive” medical practice as providers fear making mistakes, lack of knowledge about tests protocols and lack of communication regarding previous tests results.
Pathologist
Attending
Resident
Patient
Test Utilization Communication Channels
The working model for current state communication channels with Attendings and Residents communicating regularly regarding test-ordering.
We utilized a human-centered design approach to explore our problem space including on-site observations, contextual inquiry, interviewing experts, clinical providers, and patients, and leveraging design methods. For our design process we utilized the Double Diamond method focusing primarily
on future strategy recommendations.
1
2
3
4
5
Expert
Interviews
On-site
Observations
Primary
Interviews
Data
Synthesis
Final
Report
DISCOVER
DEFINE
DEVELOP
DELIVER
A.E.I.O.U.
P.E.O.M.S.
Contextual Inquiry
Affinity Map
Force Field Analysis
Mental Model
Org. Strategies
Final Report
Problem Tree
We conducted a combined total of 40 hours of observations within Michigan Medicine including the Trauma Burn Intensive Care Unit, Internal Medicine Intensive Care Unit, and the Gastroenterology department. Our observations focused on gaining a deeper understanding of clinical provider workflow, how tests are ordered and by who, and how decisions are made to determine test appropriate test in real time. We had a total of 11 interviews with Pathologists (6), Pathologist Residents (2), and Specialist Physicians (3).
Through our observations and interviews we identified two distinct ordering patterns in comparing the ICU and Non-ICU setting. We found that in the ICU context, ordering occurs in real time during rounds in the hallway with a central person ordering on a single computer. In the Non-ICU context, ordering occurs after rounds in a huddle room through a decentralized process in which various Residents order on their own computer based patient case load.
Site of Order
Order System
Who Places Order
Time of Order
ICU
Hallway
Non-ICU
Huddle Room
Central person ordering
Distributed ordering
Physician Assistant
Resident
Single-stage: computer with real-time ordering
Multi-stage: paper notes transferred to computer with delayed order
Patient Interaction
Only Doctor present
All round team present
FORCE FIELD ANALYSIS
Force Field Analysis is used to analyze the pressures or 'forces' working for and against an intended change. We used this method to aid in our decision-making regarding proposed recommendations for the Pathology department. We determined this method to be a valuable tool as it clearly identified for our partner the impediments and opportunities for behavior change.
Forces for Change
Available educational resources:
Pathology Handbook, 'Uptodate' software
Position hierarchy influencing individual behavior i.e. Attendings influence Residents
Modeling informal work environment
of Pathology across other services
Huddle room as communal decision-making location for communication
Current behavior change interventions:
Pre-test Probability decision-making process
Decision-making support tools
Pathology dashboard for behavior change
Forces Against Change
Position hierarchy influencing individual behavior i.e. Attendings influence Residents
Lack of extensive knowledge regarding which test to choose and when
Varied perceptions of test appropriateness across all positions
Perception of lack of access to specialist knowledge for ordering system
Providers perception of patient expectations for what patients describe as 'good care'
Lack of formal and regular evaluation system to provide constructive feedback regarding test utilization
Michigan Medicine academic culture leads to:
Transient Residents
Inability to appear wrong
Less questions are asked as a result
Using learning as an excuse for over-testing
MiChart issues:
Processing time
Functional and usability problems
Redundant system features
Lack of notification when test name is changed
PROBLEM TREE
A problem tree is a tool to clarify the hierarchy of problems addressed by the team within a design project; it represents high level problems or related sublevel problems. We used this method as both a data synthesis tool as well as a prioritization too to aid in our decision-making regarding which problem areas would be the first to approach for behavior change.
RECOMMENDATION ONE: Alternative Rounding Protocol to Cultivate Collaborative Open Dialogue
Instead of having only pre-rounds and rounds as a team which includes the Attending, we suggest the addition of post-rounds as a team within the huddle room in order to cultivate a sense of shared decision-making.
While Residents transition in and out of hospital units throughout their residency term, the huddle room remains a consistent location for conversation regardless of the unit. Residents grow accustom to learning from Senior Residents and Attendings within this environment and we see the huddle rooms as an opportunity to cultivate behavior change.
Typical Huddle Room Layout
Computer for Ordering
Resident
Other Staff
Proposed Huddle Room Layout
Computer for Ordering
Resident
Attending
Other Staff
RECOMMENDATION TWO: Co-design Workshop with Pathology and Attendings
To strengthen communication and connect specialist knowledge (Pathologists) to the point of ordering (Attendings and Residents), we suggest hosting a co-design workshop as an intervention to open more enriching lines of communication within the hospital.
Pathologists have key knowledge and expertise which can aid in decision-making to ensure appropriate use of resources and best care for patients. The goal of the workshop will be to not only open lines of communication, but develop shared goals and a better communication system leveraging the current tools at use within the hospital.
We presented our final recommendations to our partners with the Pathology Department DQHI and stakeholders from Michigan Medicine. One MDes student continued this project in the following year for their thesis project including prototyping and testing new tools with Internal Medicine and the Pathology department DQHI to improve behavior change.