Papers by Johanna Westbrook
Textbook of Patient Safety and Clinical Risk Management
This chapter aims to illustrate the methodologies of time and motion research, the observation of... more This chapter aims to illustrate the methodologies of time and motion research, the observation of clinical care activities in the field and its limits, strengths and opportunities. We discuss how such studies can be used to address questions related to the quality of care and to examine the relationships between clinical workflow and safety. Further, the chapter provides specific examples of the application of time and motion studies, the practical challenges and results obtained.
Studies in health technology and informatics, 2012
Medication monitoring of ambulatory rheumatology patients on Disease Modifying Anti-Rheumatic Dru... more Medication monitoring of ambulatory rheumatology patients on Disease Modifying Anti-Rheumatic Drugs (DMARDS) is time consuming and complex, with possibilities for error. Electronic systems have the potential to improve the process. The aim of this study was to evaluate the impact of an electronic Drug Monitoring System (eDMS) on the time nurses' spent on clinical documentation associated with monitoring. The study was conducted with all nurses (n=4) in the Rheumatology Department of a large metropolitan Australian teaching hospital. The eDMS was designed as a module of the Hospital Clinical Information System (HCIS) to assist clinicians in monitoring rheumatology patients on DMARDS. Timing data were collected using a modified time and motion work measurement technique using software on a handheld computer. Data included the time nurses spent on documentation regarding medication monitoring before and after the implementation of the eDMS. Results showed that following implementat...
Studies in health technology and informatics, 2013
The aim of this study was to examine the impact of the Electronic Medical Record (EMR) on the qua... more The aim of this study was to examine the impact of the Electronic Medical Record (EMR) on the quality of laboratory test orders made by clinicians. The study assessed the type and frequency of pre-analytical laboratory test order errors that were associated with the EMR across three hospitals and one pathology service. This involved a retrospective audit of the laboratory error logs for the period 1 March 2010 to 9 October 2011. Test order problems associated with the EMR occurred at a total rate of 1.34 per 1000 test order episodes across the three hospitals. In the majority of cases these errors were caused by the inappropriate use of the EMR system by clinicians. The errors resulted in increased data entry time for laboratory staff in the Central Specimen Reception area and led to a median increase of 181 minutes in test turnaround times for those test orders. The study highlights the importance of monitoring and comparing the impact of EMR systems in different locations over tim...
Studies in health technology and informatics, 2015
In this study we examined the impact of an Electronic Medical Record (EMR) on repeat test rates (... more In this study we examined the impact of an Electronic Medical Record (EMR) on repeat test rates (i.e., the same test ordered within a specified window of time) for a commonly ordered set of laboratory tests; Electrolytes, Urea, Creatinine [EUC], Full Blood Counts [FBC] and Liver Function Tests [LFT]. The results point to the potential that timely, evidence-based electronic decision support features can have on the efficiency and effectiveness of the pathology laboratory process and its contribution to quality patient care.
Studies in health technology and informatics, 2016
The after hours GP helpline (AGPH), one of the key services provided by Healthdirect, is an exten... more The after hours GP helpline (AGPH), one of the key services provided by Healthdirect, is an extension of the existing healthdirect telephone nurse triage and advice service. It provides access to telephone health advice by GPs after hours to patients/callers who are triaged by the telephone nurse as needing to see a GP immediately, within four hours or within 24 hours. The aims of this study were to assess patient satisfaction with the AGPH service and compliance with the GP advice; and to investigate factors associated with patients' compliance. This study included 2486 patients/callers who used the AGPH and participated in a survey between February and September 2013. Over 97.1% of patients/callers were either satisfied or very satisfied with the AGPH service. Compliance was measured in two ways: i) self-reported compliance to advice provided; and ii) matching of self-reported actions with actual GP advice given: 94.0% of patients reported they followed the advice given to the...
Studies in health technology and informatics, 2013
Health information technology (IT) can have a profound effect on the temporal flow and organisati... more Health information technology (IT) can have a profound effect on the temporal flow and organisation of work. Yet research into the context, meaning and significance of temporal factors remains limited, most likely because of its complexity. This study outlines the role of communications in the context of the temporal and organizational landscape of seven Australian residential aged care facilities displaying a range of information exchange practices and health IT capacity. The study used qualitative and observational methods to identify temporal factors associated with internal and external modes of communication across the facilities and to explore the use of artifacts. The study concludes with a depiction of the temporal landscape of residential aged care particularly in regards to the way that work is allocated, prioritized, sequenced and coordinated. We argue that the temporal landscape involves key context-sensitive factors that are critical to understanding the way that humans...
Studies in health technology and informatics, 2017
Electronic medical record-based test results management interventions hold the potential to reduc... more Electronic medical record-based test results management interventions hold the potential to reduce errors in the test result follow-up process. However, ensuring the adaptability of such systems to the clinical environment has proven challenging. The aim of this study was to explore how contextual factors can influence senior emergency physicians' experience and perceived impacts of an electronic result acknowledgement system across two Emergency Departments. Semi-structured, in-depth interviews relating to physician test result acknowledgement processes before and after system implementation were conducted with 14 senior Emergency Physicians across two Australian metropolitan teaching hospitals. Perceived impacts of the electronic test result acknowledgement system on test result endorsement varied in terms of: changes to workflow, impacts on patient safety; and changes to documentation practices. Existing work practices and the departmental staffing mix and roles play a part i...
Studies in health technology and informatics, 2018
Pending laboratory test results at discharge can have major adverse health outcomes. The availabi... more Pending laboratory test results at discharge can have major adverse health outcomes. The availability of test results at discharge may depend on whether the tests were ordered electronically or by using a paper-based system. The aim of this study was to determine the rate of pending test results at time of discharge from Emergency Departments (ED), and compare the rate for paper-based and electronic orders across three EDs in New South Wales, Australia. This retrospective study described 71,466 ED presentations with 357,476 laboratory tests across three years (2014-2016). Only patients who were treated in ED and eventually discharged from ED were included. Most tests were ordered using the electronic system (97.2%, n=347,469). The rate of pending test results was significantly lower for electronic orders (6.6%, n=22,928) than for paper orders (9.7%, n=966): a difference of 3.1%. Similar differences were observed when analysis was done by year of ED presentation. Moreover, in a subgr...
Studies in health technology and informatics, 2017
The roll-out of a hospital-wide electronic medication management system (eMMS) is a challenging t... more The roll-out of a hospital-wide electronic medication management system (eMMS) is a challenging task, requiring planning, coordination, communication and change management. This research aimed to explore the views of doctors and nurses about the strategy used to implement an eMM system in a paediatric hospital. Semi-structured interviews were performed during the first week of the implementation on each ward, and were then followed up three and six weeks post implementation. In total, 90 users (60 nurses and 30 doctors) were asked about their impressions of the implementation, as well as their perceptions of training and IT support. Qualitative thematic analysis was performed by three researchers. Most users perceived the implementation of the eMM to be positive overall. Although perceptions of the implementation process remained largely consistent across the six weeks, users identified several areas where improvements were needed, especially early in implementation, including resou...
In Australia, New South Wales Health Pathology's implementation of managed Point-of-Care Test... more In Australia, New South Wales Health Pathology's implementation of managed Point-of-Care Testing (PoCT) services across rural and remote emergency departments (EDs) has the potential to significantly improve access to results for certain types of pathology laboratory tests and help to deliver timely patient care. The aim of this study was to assess the quality of the datasets, including the integration of PoCT results into clinical systems, as a precursor to the application of an evaluation framework for monitoring the delivery of PoCT services and their impact on patient care. Three datasets, including laboratory, ED presentations and hospital admissions data were extracted from the relevant clinical information systems. Each dataset was assessed on six dimensions: completeness, uniqueness, timeliness, validity, accuracy, and consistency. Data incompleteness was the largest problem. Assessing the PoCT data integration and data quality is a precondition for the evaluation of PoC...
The Electronic Medical Record (EMR) incorporates computerised provider order entry systems which ... more The Electronic Medical Record (EMR) incorporates computerised provider order entry systems which allow clinicians to order diagnostic tests electronically, thus eliminating the need for cumbersome handwritten orders. In many situations the EMR relies on a manual transition of information across systems (e.g., integration with the Laboratory Information System). This study, based in a laboratory setting requiring such a transition across systems, aimed to compare the data entry time (from when a specimen arrives in the Central Specimen Reception [CSR] area of the laboratory, to when it is forwarded on for processing), along with a laboratory turnaround time (TAT) (from the time a specimen is received to the time a verified result is issued) for paper and EMR orders, for two high volume tests, across six hospitals. Results showed that the median data entry time for all hospitals combined, was three minutes shorter for EMR entered orders than paper orders. This difference was consisten...
Medication information is a critical part of the information required to ensure residents' sa... more Medication information is a critical part of the information required to ensure residents' safety in the highly collaborative care context of RACFs. Studies report poor medication information as a barrier to improve medication management in RACFs. Research exploring medication work practices in aged care settings remains limited. This study aimed to identify contextual and work practice factors contributing to breakdowns in medication information exchange in RACFs in relation to the medication administration process. We employed non-participant observations and semi-structured interviews to explore information practices in three Australian RACFs. Findings identified inefficiencies due to lack of information timeliness, manual stock management, multiple data transcriptions, inadequate design of essential documents such as administration sheets and a reliance on manual auditing procedures. Technological solutions such as electronic medication administration records offer opportuni...
The aim of this study was to examine the actions of geographically dispersed process stakeholders... more The aim of this study was to examine the actions of geographically dispersed process stakeholders (doctors, community pharmacists and RACFs) in order to cope with the information silos that exist within and across different settings. The study setting involved three metropolitan RACFs in Sydney, Australia and employed a qualitative approach using semi-structured interviews, non-participant observations and artefact analysis. Findings showed that medication information was stored in silos which required specific actions by each setting to translate this information to fit their local requirements. A salient example of this was the way in which community pharmacists used the RACF medication charts to prepare residents' pharmaceutical records. This translation of medication information across settings was often accompanied by telephone or face-to-face conversations to cross-check, validate or obtain new information. Findings highlighted that technological interventions that work in...
New South Wales (NSW) Health Pathology is implementing one of the world's largest managed PoC... more New South Wales (NSW) Health Pathology is implementing one of the world's largest managed PoCT services across rural and remote Emergency Departments (EDs) in New South Wales, Australia to improve patient access to care. The aim of this qualitative study was to gain a context-rich understanding of the operational impact of the NSW rollout of PoCT across rural and remote ED settings as experienced by frontline clinical staff. Clinical professionals (n=14) participated in interviews and focus groups in August 2015 at four rural and remote NSW EDs. Participants perceived that PoCT provided greater access to pathology thus facilitating more efficient and effective patient care via faster test turnaround and time to treatment and more effective decisions about the need to transfer patients to appropriate sites when required. These factors have a potentially important role in saving lives. Staff also identified innovative and disruptive challenges to clinical work patterns associated ...
The challenge of providing services that meet the growing needs of an ageing population is one co... more The challenge of providing services that meet the growing needs of an ageing population is one confronted by communities across Australia and internationally. The aim of this study was to: a) undertake semi-structured interviews and focus groups across a sample of service and technical staff to identify the interconnection between communication, information, work practices and performance; and b) carry out a comprehensive review of existing data sources to identify the data linkages required to identify and monitor performance across different dimensions of the quality of aged care spectrum. The results from this study provided empirical evidence of the interconnection between communication, information, work practices and performance; and highlighted numerous potential data linkages which can be used to monitor performance across different dimensions of aged care. These included: the uptake and utilisation of community care services, community aged care client interactions and tran...
Studies in health technology and informatics, 2011
Picture Archiving and Communication Systems (PACS) allow the fast delivery of imaging studies to ... more Picture Archiving and Communication Systems (PACS) allow the fast delivery of imaging studies to clinicians at the point-of-care, supporting quicker decision-making. PACS has the potential to have a significant impact in the Intensive Care Unit (ICU) where critical decisions are made on a daily basis, particularly during ward rounds. We aimed to examine how accessing image information is integrated into ward rounds and if the presence of PACS produced innovations in ward round practices. We observed ward rounds and conducted interviews with ICU doctors at three hospitals with differing levels of PACS availability and computerization. Imaging results were infrequently viewed by clinicians during ward rounds in two ICUs: one without PACS and one which had both PACS and bedside computers. In the third ICU, where PACS was only available at a central workstation, images were frequently viewed throughout the daily round and integrated into decisions about patient care. The presence of bed...
Studies in health technology and informatics, 2014
Electronic ordering systems have the potential to enhance the efficient utilisation of pathology ... more Electronic ordering systems have the potential to enhance the efficient utilisation of pathology services. The aim of this study was to assess the effect of electronic pathology ordering on repeat test ordering for paediatric patients (ages 0 to 18 years) who were in intensive care units (ICUs) and non-ICU wards. The dataset described 85,728 pathology tests ordered for 5,073 children before and after the implementation of electronic ordering. This study showed that, for children in ICUs, the repeat test order rate was significantly lower for electronic orders than for paper-based orders. Similarly, the rate of repeat tests ordered within short intervals (up to 23-hours), for children older than one-year in non-ICU wards, was lower for electronic ordering than for paper ordering. The proportion of repeat tests occurring within one-hour of the previous test was consistently lower for tests ordered using electronic ordering than it was for tests ordered using the paper based system for...
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Scientific Reports
Low serum ferritin is diagnostic of iron deficiency, yet its published lower cut-off values are h... more Low serum ferritin is diagnostic of iron deficiency, yet its published lower cut-off values are highly variable, particularly for pediatric populations. Lower cut-off values are commonly reported as 2.5th percentiles, and is based on the variation of ferritin values in the population. Our objective was to determine whether a functional approach based on iron deficient erythropoiesis could provide a better alternative. Utilizing 64,443 ferritin test results from pediatric electronic health records, we conducted various statistical techniques to derive 2.5th percentiles, and also derived functional reference limits through the association between ferritin and erythrocyte parameters: hemoglobin, mean corpuscular volume, mean cell hemoglobin concentration, and red cell distribution width. We find that lower limits of reference intervals derived as centiles are too low for clinical interpretation. Functional limits indicate iron deficiency anemia starts to occur when ferritin levels reac...
Medical Journal of Australia
nprofessional behaviour among hospital workers, ranging from incivility and bullying to violence,... more nprofessional behaviour among hospital workers, ranging from incivility and bullying to violence, is frequent, 1,2 and it affects care delivery and patient safety. In a United States study (including 13 653 patients and 202 surgeons), rates of medical and surgical complications for individual surgeons were significantly associated with the number of reports by coworkers of their unprofessional behaviour. 3 Unprofessional behaviour often draws attention, but the insidious effects of incivility on safety are becoming clearer. 4 Simulation studies have found that even mild incivility causes significant declines in clinical team functioning and care outcomes. 5,6 A multicentre study found that incivility during a simulated operating theatre crisis was associated with significantly poorer clinical performance by resident anaesthetists. 7 Major health care inquiries have found that hospital cultures in which unprofessional behaviour is tolerated contribute to breaches in safety practices and poor patient outcomes. 8 "Speaking up" programs are designed to counter such cultures by supporting open communication by staff about both immediate problems for patient safety (eg, poor hand hygiene among staff) and unprofessional behaviour (eg, incivility, bullying) that compromise teamwork and safe care delivery. The importance of providing employees with skills in speaking up (ie, effectively and assertively communicating views and ideas) is critical to ensuring patient safety and staff wellbeing. 9 Health systems around the world have invested in programs that encourage staff to speak up. For example, the National Guardian Freedom to Speak-up Office, established following the Francis inquiry into the Stafford Hospital scandal in the United Kingdom, 8 has developed speaking-up training and appointed more than 800 guardians across the National Health Service. Guardians received more than 1000 reports per month during 2019-more than one-third included elements of bullying and harassment 10-illustrating that patient safety concerns are often linked with unprofessional behaviour. Despite investments in speaking-up programs, including by Australian hospitals, their effectiveness in reducing rates of unprofessional behaviour or improving safety has not been investigated. Evidence for the effectiveness of organisational interventions for reducing unprofessional behaviour is limited. 11 Effective interventions depend upon detailed understanding of the nature and impact of such behaviour and of factors that place particular groups at risk. While rates of unprofessional behaviour in hospitals have been assessed in surveys, 12-14 its nature and extent
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Papers by Johanna Westbrook