Presentation
HE4 - A Work Systems Analysis of Labor and Delivery During Cesarean Deliveries
SessionPoster Session 2
DescriptionMaternal health is a global safety and equity issue. In the USA maternal mortality and morbidity is amongst the worst in the developed world, with the burden of poor outcomes and accidental harm largely bourn by women of color. Pregnancy represents a care journey that involves different types of healthcare organizations. Primary labor and delivery units consist of anesthesia, nursing, surgeons, and certified surgical technicians, but can be supported by other teams (e.g., neonatal intensive care nurses, respiratory therapy). The labor and delivery department represents a unique healthcare specialty where mother and baby start as a symbiotic unit and then become two independent patients upon delivery.
The goal of system safety is to maintain the safety of all of the different system elements including the people, environment, and technology. System safety in healthcare means maintaining safety of the patients, clinicians, care environments (e.g., labor and delivery units), and tools (e.g., surgical equipment). Patient safety is influenced by the environment, care quality, technology, human factors, and the Food and Drug Administration (Choudhury & Asan, 2020). The Systems Engineering Initiative for Patient Safety (SEIPS; Carayon et al., 2006; Carayon et al., 2020; Holden et al., 2013) provides a framework for understanding the complexity of healthcare work systems. With the expansion and integration of technology into clinical environments, healthcare teams can be understood through the interactions between the humans (providers or patients) and the technology (e.g., human-computer interaction). The SEIPS 101 Tools (Holden & Carayon, 2021) provide a set of methods to provide clarity and understanding of a clinical work system from a patient safety perspective.
Despite the associated risks with cesarean deliveries, the number of mothers seeking to deliver via cesarean sections is increasing. The purpose of this work was to better understand complex healthcare work systems by investigating the effect of provider type on normal care processes within labor and delivery, specifically planned cesarean deliveries, using the SEIPS 101 tools.
Thirty -two procedures were observed over 124 hours at a southeastern academic hospital featuring 250 pediatric beds and 29 adult beds. The primary locations for the observations included the operating rooms, pre-operation holding rooms, post-anesthesia care unit rooms, and provider workstations. This work systems analysis used the SEIPS 101 tools to describe labor and delivery care during cesarean deliveries. A process map was used to describe the cesarean delivery care process including activities, decisions, and delays from the time the labor and delivery staff first contact the patient to the time the patients leave the labor and delivery unit. Thirteen delays were identified during the observations, eight associated with the clinical providers, three related to the patients, and two for technology. A people map shows communication complexities within the operating room due to the number of participants (i.e., care providers, primary patients, and secondary patients) and type of communication (i.e., one-way vs. two-way communication). For this work primary patients were classified as the mother and baby and the additional family member (e.g., father) was classified as a secondary patient. Two-way communication occurs being eight clinical teams and two patient groups (i.e., mother and family). One-way communication was associated with any verbal interactions with the baby. The task and tools matrices provide an overview of the required equipment and responsibilities of different team members during a cesarean section delivery. The task and tools matrices demonstrate how the dependencies of the care teams on the actions of the other teams and the tools available to them throughout the care processes.
The findings from this work demonstrates the complexity of the labor and delivery work system and supports previous systems descriptions for having the human and their behavior at the center of the system, but influenced by other factors (e.g., the environment, tools, organization; Carayon et al., 2006; Choudhury & Asan, 2020; Zhang et al., 2004). Using a systems approach to describing the work system shows that efficiency of labor and delivery work environments are associated with factors that are often outside of the frontline providers control, such as individual patient differences or technology failures. Frontline providers have to communicate and coordinate with other care teams, but also do so while managing the emotions of their patients. Safety II pushes for a better understanding for work-as-done compared to work-as-imagined, and this work provides a foundation for better understanding live clinical work.
This work helps describe how care is provided under expected circumstances during a cesarean delivery although healthcare delivery can rarely be defined as “routine”. Using a systems approach to understanding the labor and delivery work system identified several challenges encountered by the frontline staff. The ability of the labor and delivery team to perform their work relies on the ability of other teams to complete their work, such as the sterile processing department (SPD). The sterile processing department is responsible for cleaning and sterilizing the surgical tools used in operating rooms. The observations identified some of the challenges faced by the operating room staff related to the surgical instruments. While SPD performance influences operating room efficiency, a systems analysis of the SPD using the SEIPS 101 tools identified several factors influencing SPD outcomes (Segarra et al., 2024). Teams are required to adjust their procedures when there are multiple babies, emergency deliveries, or patients with high body mass indices. When staff encounter more unique situations it is possible that the treatment location, number of staff, or procedures change to accommodate for the variation. Future work includes opportunities to investigate how work adaptations occur within complex healthcare environments, specifically labor and delivery, or how teams outside of the department influence care efficiency. Embedded human factors practitioners are outside observers capable of capturing how work is completed under regular performance or how work changes under unique circumstances. The collected observations for work under regular or unique circumstances can be analyzed to showcase work complexity to hospital leaders that may not fully grasp the difficulties associated with patient care.
The goal of system safety is to maintain the safety of all of the different system elements including the people, environment, and technology. System safety in healthcare means maintaining safety of the patients, clinicians, care environments (e.g., labor and delivery units), and tools (e.g., surgical equipment). Patient safety is influenced by the environment, care quality, technology, human factors, and the Food and Drug Administration (Choudhury & Asan, 2020). The Systems Engineering Initiative for Patient Safety (SEIPS; Carayon et al., 2006; Carayon et al., 2020; Holden et al., 2013) provides a framework for understanding the complexity of healthcare work systems. With the expansion and integration of technology into clinical environments, healthcare teams can be understood through the interactions between the humans (providers or patients) and the technology (e.g., human-computer interaction). The SEIPS 101 Tools (Holden & Carayon, 2021) provide a set of methods to provide clarity and understanding of a clinical work system from a patient safety perspective.
Despite the associated risks with cesarean deliveries, the number of mothers seeking to deliver via cesarean sections is increasing. The purpose of this work was to better understand complex healthcare work systems by investigating the effect of provider type on normal care processes within labor and delivery, specifically planned cesarean deliveries, using the SEIPS 101 tools.
Thirty -two procedures were observed over 124 hours at a southeastern academic hospital featuring 250 pediatric beds and 29 adult beds. The primary locations for the observations included the operating rooms, pre-operation holding rooms, post-anesthesia care unit rooms, and provider workstations. This work systems analysis used the SEIPS 101 tools to describe labor and delivery care during cesarean deliveries. A process map was used to describe the cesarean delivery care process including activities, decisions, and delays from the time the labor and delivery staff first contact the patient to the time the patients leave the labor and delivery unit. Thirteen delays were identified during the observations, eight associated with the clinical providers, three related to the patients, and two for technology. A people map shows communication complexities within the operating room due to the number of participants (i.e., care providers, primary patients, and secondary patients) and type of communication (i.e., one-way vs. two-way communication). For this work primary patients were classified as the mother and baby and the additional family member (e.g., father) was classified as a secondary patient. Two-way communication occurs being eight clinical teams and two patient groups (i.e., mother and family). One-way communication was associated with any verbal interactions with the baby. The task and tools matrices provide an overview of the required equipment and responsibilities of different team members during a cesarean section delivery. The task and tools matrices demonstrate how the dependencies of the care teams on the actions of the other teams and the tools available to them throughout the care processes.
The findings from this work demonstrates the complexity of the labor and delivery work system and supports previous systems descriptions for having the human and their behavior at the center of the system, but influenced by other factors (e.g., the environment, tools, organization; Carayon et al., 2006; Choudhury & Asan, 2020; Zhang et al., 2004). Using a systems approach to describing the work system shows that efficiency of labor and delivery work environments are associated with factors that are often outside of the frontline providers control, such as individual patient differences or technology failures. Frontline providers have to communicate and coordinate with other care teams, but also do so while managing the emotions of their patients. Safety II pushes for a better understanding for work-as-done compared to work-as-imagined, and this work provides a foundation for better understanding live clinical work.
This work helps describe how care is provided under expected circumstances during a cesarean delivery although healthcare delivery can rarely be defined as “routine”. Using a systems approach to understanding the labor and delivery work system identified several challenges encountered by the frontline staff. The ability of the labor and delivery team to perform their work relies on the ability of other teams to complete their work, such as the sterile processing department (SPD). The sterile processing department is responsible for cleaning and sterilizing the surgical tools used in operating rooms. The observations identified some of the challenges faced by the operating room staff related to the surgical instruments. While SPD performance influences operating room efficiency, a systems analysis of the SPD using the SEIPS 101 tools identified several factors influencing SPD outcomes (Segarra et al., 2024). Teams are required to adjust their procedures when there are multiple babies, emergency deliveries, or patients with high body mass indices. When staff encounter more unique situations it is possible that the treatment location, number of staff, or procedures change to accommodate for the variation. Future work includes opportunities to investigate how work adaptations occur within complex healthcare environments, specifically labor and delivery, or how teams outside of the department influence care efficiency. Embedded human factors practitioners are outside observers capable of capturing how work is completed under regular performance or how work changes under unique circumstances. The collected observations for work under regular or unique circumstances can be analyzed to showcase work complexity to hospital leaders that may not fully grasp the difficulties associated with patient care.
Event Type
Poster Presentation
TimeTuesday, April 14:45pm - 6:15pm EDT
LocationFrontenac Foyer