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Understanding work-as-done in the ED: New approaches to addressing the challenges of patient flow
Abstract   Peer reviewed

Understanding work-as-done in the ED: New approaches to addressing the challenges of patient flow

E Austin, R Clay-Williams, E Auton, R Ali, C Dooley, H Zaouk, Paul M Salmon and Jeffrey Braithwaite
Emergency Medicine Australasia, Vol.32(Supplement 1), p.55
ACEM Annual Scientific Meeting: The Changing Climate of Emergency Medicine, 36th (Hobart, Australia, 17-Nov-2019–21-Nov-2019)
2020
DOI: https://doi.org/10.1111/1742-6723.13475
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https://doi.org/10.1111/1742-6723.13475View
Published Version

Abstract

Clinical Sciences Public Health and Health Services
Background: Patient flow through the emergency department (ED) is a key hospital performance measure, determined by factors including the volume of patients arriving to be seen, the time taken to assess and treat patients, and availability of beds in hospital wards. To develop strategies to improve patient flow, we need to better understand work-as-done in the ED, including the constraints that bound potential solutions. Objectives: Using Cognitive Work Analysis (CWA) and Functional Resonance Analysis Method (FRAM), the study aimed to develop an in-depth understanding of patient flow problems within the ED and identify potential sustainable patient flow interventions. Methods: Publicly available documents (e.g., policies, guidelines), and 263 h of observations in a tertiary public hospital ED were reviewed, thematically analysed and modelled. Results: CWA and FRAM models identified differences between work-as-imagined in the ED compared with work-as-done. Analyses identified workplace constraints, potential modifications (e.g., multiple communication pathways) and impediments (e.g., IT system speed and maintenance practices) to maintain safe and timely care. Areas for process improvement include communication, administration, equipment and stakeholder engagement. Conclusions: A comprehensive, systematic and contextual description of the ED system was developed for the first time, illustrating the complexity and resilience of an ED with multiple measures, functions, capabilities and physical resource limitations. Using the CWA and FRAM, improvement recommendations can be generated that take into account the contextual information of the wider system. These findings have significant implications for designing interventions to align work-as-imagined and work-as-done in ED to support and improve patient safety.

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