Engineering High Reliability Learning Lab (EHRLL)

Principal Investigator: Sara Singer, Ph.D., Harvard University, Cambridge, MA
AHRQ Grant No.: HS24453
Project Period: 09/30/15–09/29/21
Description: The goal of this learning lab was to enhance capacity for innovation and develop highly reliable systems that address communication and coordination challenges that pose patient safety risks at the intersection of primary and specialty care. A five-stage systems engineering cycle, including problem analysis, design, development, implementation, and evaluation, drove the lab’s efforts to develop highly reliable systems within four Harvard-affiliated primary care practices and their specialty care partners.

The specific aims were to:

1. Build a shared infrastructure that comprised an administrative/learning core, an engineering core, and multidisciplinary teams to stimulate a systematic approach for patient safety innovation.
2. Engage in three research projects that applied systems engineering to the development of innovative solutions for improving health information technology-supported processes and designing highly reliable systems that are generalizable.
3. Implement and spread redesigned systems across a range of hospital/community-based primary care practices and test systems’ generalizability in alternative settings and conditions.
4. Assess the impact of redesigned systems on practice, team, provider, and patient outcomes and disseminate findings, tools, and resources for national replication.

Over 5 years, four synergistic projects engaged health system-based reengineering and design teams in problem analysis and hands-on development, testing, and implementation of:

1. More reliable closed-loop systems for primary care referrals to specialists external to the health system.
2. Coordination systems for children with medical complexity undergoing surgery.
3. Enhanced safety for opioid prescription management processes for adults in a primary care clinic.
4. Reliable communication and coordination systems between primary and home health care providers for patients with complex care needs following hospital discharge.

EHRLL used a variety of systems engineering and problem analysis tools at four institutions to facilitate a successful learning system and find solutions to problems relevant to each institution.¹ These tools included process mapping, swim lane diagrams, functional resonance analysis method, failure modes and effects analysis, contrast analysis, run charts, and predictive modeling dashboards.

EHRLL researchers developed a model of the constraint management process to show that each institution’s teams over time experienced hierarchical and heterarchical constraints.² They used direct and indirect tactics to overcome these constraints and ultimately helped each institution achieve milestones and maintain momentum.

Researchers also developed a model describing how perceptions of patient engagement evolves on design teams over time.³ They suggest that patients may engage in a range of roles, including as informants, partners, and active change agents and that perceptions of a patient’s role can influence and be influenced by how they act and contribute on design teams.

Through their self-evaluation,⁴ researchers showed how a patient safety learning lab can help foster interdisciplinary team innovation across multiple projects and institutions by creating an ecosystem focused on deploying systems engineering methods to accomplish process redesign. They demonstrated that successful learning ecosystems continually create alignment—interpersonal/interprofessional, informational, structural, and processual—between interdisciplinary teams’ activities, organizational context, and innovation project objectives.

One of the lab’s successes was at Boston Children’s Hospital, which created a new approach to patient engagement. They redefined the facility’s care pathway and spread this care pathway across the United States via the American Academy of Cerebral Palsy and Developmental Medicine.⁵ The hospital is now using the same systems engineering methods to cope with COVID-19.

In one Boston Children’s Hospital’s project, the team looked at preoperative health evaluations of children with neuromuscular scoliosis undergoing spinal fusion. They assessed the impact of having complex care pediatricians (CCPs) conduct these evaluations instead of anesthesiologists, who usually conduct them.⁶

Researchers found the average number of last-minute care coordination activities required for surgical clearance was lower for children with CCP evaluation versus children without CCP evaluation (1.8 vs. 3.6). About 26 percent of children with CCP evaluation required last-minute development of new preoperative plans compared with about 50 percent of children without CCP evaluation. The difference of the percentages is statistically significant. Children with CCP involvement were better prepared for surgery, requiring fewer last-minute care coordination activities for surgical clearance.⁶

The project team at Brigham and Women’s Hospital developed a system of workflows to improve management of chronic opioid prescribing.^5,7 Overcoming constraints (e.g., loss of patient contact when new workflows called for transition from paper-based to electronic prescriptions, disruptions due to high turnover) required ongoing adaptation and rapid iteration. In addition, it required cooperation among disciplines and departments, alignment of resources outside the clinic, and a coordinating role by pharmacists/pharmacy technicians.

Lessons learned suggest future work should involve multidisciplinary teams, risk-based stratification, improved patient contact (especially in light of remote care), and meaningful interpretation of urine drug results to inform appropriate care of patients on chronic opioid therapy. The objective is to promote partnership between clinicians and patients and create a “community of care” that overcomes stigma, barriers, and inefficiencies to address this important clinical and social problem.

In response to COVID-19, EHRLL’s engineering core team developed the Northeastern University Hospital Surge Capacity Planning Model. This model helps health systems estimate and visualize 1- to 30-day ahead hospital-specific demand for key resources, including medical and intensive care beds, ventilators, personal protective equipment, medications, and available staff on a rolling basis. The tool was made freely available to any health system worldwide. It has been viewed more than 17,000 times in all 50 States and more than 90 countries, as well as more than 200 health systems registered to receive updated versions.

This PSLL's work has resulted in 19 peer-reviewed journal publications.

Publications

In press

• Carlile N, et al. Lessons learned in implementing a chronic opioid therapy management system. J Patient Saf, in press.

2022

• Atkinson MK, et al. Evaluating a patient safety learning lab intervention to create an interdisciplinary ecosystem for healthcare innovation. Health Care Manage Rev 2022 Jan 27.

2021

• Berry JG, et al. Hospital resource use after hip reconstruction surgery in children with neurological complex chronic conditions. Dev Med Child Neurol 2021;63(2):204-10.
• Lewen MO, et al. Preoperative hematocrit and platelet count are associated with blood loss during spinal fusion for children with neuromuscular scoliosis. J Perioper Pract 2022 Apr;32(4):74-82.
• Atkinson MK, et al. Patient engagement in system redesign teams: a process of social identity. J Health Organ Manag 2021;ahead-of-print(ahead-of-print):10.1108/JHOM-02-2021-0064.

2020

• Garrity BM, et al. Parent perspectives on short-term recovery after spinal fusion surgery in children with neuromuscular scoliosis. J Patient Exp 2020;7(6):1369-77.
• Atkinson M, Singer S. Managing organizational constraints in innovation teams: a qualitative study across four health systems. Med Care Res Rev 2020 Oct;78(5):521-36.
• Atkinson M and Singer S. Social identity and the patient engagement experience in quality improvement teams. Academy of Management Annual Meeting Proceedings 2020 Aug;(1):17486. ISSN: 2151-6561.

2019

• Berry JG, et al., Pediatric complex care and surgery comanagement: preparation for spinal fusion. J Child Health Care 2020 Sep;24(3):402-10.
• Berry JG, et al. Predicting postoperative physiologic decline after surgery. Pediatrics 2019 Apr;143(4):e20182042.
• Garrity B, et al. Parent-to-parent advice on considering spinal fusion in children with neuromuscular scoliosis. J Pediatr 2019 Oct;213:149-54.
• Gay JC, et al. Association of extending hospital length of stay with reduced pediatric hospital readmissions. JAMA Pediatr 2019 Feb 1;173(2):186-88.
• Glotzbecker M, et al. Implementing a multidisciplinary clinical pathway can reduce the deep surgical site infection rate after posterior spinal fusion in high-risk patients. Spine Deform 2019 Jan;7(1):33-39.

2018

• Bargal B, et al. Use of systems-theoretic process analysis to design safer opioid prescribing processes. IISE Trans Occup Ergon Hum Factors 2018;6(3-4):200-8. https://www.tandfonline.com/doi/abs/10.1080/24725838.2018.1521887.
• Berry J, et al. Last-minute care for pre-anesthetic clearance in children with neuromuscular scoliosis undergoing spinal fusion. Dev Med Child Neurol 2018;60(S3):40-49.
• Berry J, et al. Risk factors for increased blood loss during spinal fusion for children with neuromuscular scoliosis. Dev Med Child Neurol 2018;60(S3):108-9.
• Das P, et al. Engineering safer care coordination from hospital to home: lessons from the USA. Future Healthc J 2018;5(3):164-70.

2017

• Berry JG, et al. Comorbidities and complications of spinal fusion for scoliosis. Pediatrics 2017 Mar;139(3):e20162574.
• Berry JG, et al. Perioperative spending on spinal fusion for scoliosis for children with medical complexity. Pediatrics 2017;140(4)”e201171233.

References

1. Singer S. Progress Report: Engineering Highly Reliable Learning Lab. Boston, MA: Harvard School of Public Health; 2018.
2. AFYA, PSLL CONNECT Newsletter: Vol. 1, Issue 11. 2020. [Internal Communication]: AHRQ. p. 1-9.
3. Atkinson MK, et al. Patient engagement in system redesign teams: a process of social identity. J Health Organ Manag 2021 Oct 26;ahead-of-print(ahead-of-print).
4. Atkinson MK, et al., Evaluating a patient safety learning lab intervention to create an interdisciplinary ecosystem for healthcare innovation. Health Care Manage Rev 2022 Jan 27.
5. AFYA, PSLL CONNECT Newsletter: Vol. 2, Issue 1. 2021. [Internal Communication]: AHRQ. p. 1-9.
6. Berry JG, et al. Pediatric complex care and surgery comanagement: preparation for spinal fusion. J Child Health Care 2020;24(3):402-10.
7. Carlile N, et al. Lessons learned in implementing a chronic opioid therapy management system. J Patient Saf, in press.