Hospitals only achieve a high level of patient safety if the workplaces of all their employees are optimally designed. Things can become life-threatening when doctors and nursing staff have not been properly trained – or when unnecessary interruptions in the operating room cause mistakes. Dr. Carsten Ostendorp at the Center for Industrial and Organizational Psychology in Hospitals, ZAK (German: Zentrum für Arbeitspsychologie und Organisationspsychologie in Kliniken) spoke about this topic with MEDICA.de.
Dr. Ostendorp, how did the collaboration with hospitals come to be?
Carsten P. Ostendorp: The idea originated with a doctor friend of mine who frequently complained about hospital situations that pertained to the collaboration between the physician team or advanced and continuing education for example. I offered my professional expertise since industrial and organizational psychology provides options to work on the various issues that play a significant role in hospitals. In this concrete example, the hospital complained that it was not able to provide expert advanced and continuing education for its resident physicians. That’s why we began to take a look at the structures and processes from an industry psychology perspective. In this instance, we focus on the work task a physician or a team needs to handle. We put it into a systemic correlation. We refer to ”human-technology-organization“ in this case. The methods of industrial psychology that we use in this sociotechnical approach to human-technology-organization are highly evidence-based and able to prove effectiveness.
Can you give us an example of how you approach an analysis?
Ostendorp: We ask ourselves how the task is designed. What do interfaces to other tasks look like? To find out, we accompany medical specialists or heads of departments for one day for example. We call this a job analysis. A prior defined classification system assists in categorizing the tasks a physician performs throughout the day. In a job analysis, we show that the distances employees overcome already take up 10 percent of their working hours in some hospitals, that patient-related administrative tasks take up a lot of working time and that relatively little time remains for medical measures for example. This gives us an indication that A. the layout isn’t right, B. there are contradicting tasks and C. we have to specifically analyze the processes and structures on the work system level. Another aspect are work interruptions. We know that interruptions are very problematic in the working process and trigger stress on the psychological and physiological level. On the one hand, it makes us forget things we actually wanted to do. This causes mistakes and the impression the human being is to blame for these mistakes. Oftentimes they are not the ones responsible but rather the structure that surrounds them. When you design tasks and work systems properly, interruptions in daily work life can be significantly reduced. On the other hand, we need additional time and energy to resume the interrupted task again and continue. Of course, there are interruptions that are an innate part of the task, especially in hospitals if an emergency occurs at a station for instance. Interruptions in the operating room, however, can do great harm and are about as dangerous as lack of hygiene for example. You can define the best and highest standard of hygiene, but when the doctor is frequently interrupted, increased infections or other unwanted events can occur.
That sounds dangerous. How do you initiate changes?
Ostendorp: We work based on the conditions. That means, we first look at the context the task is embedded in and try to design the conditions in a way to where humans are supported in managing the task. We subsequently take a look at the individual person whom we are able to help with additional training or advanced and continuing education. However, when the negative conditions are not being changed, any type of continuing education is only a compensatory measure.
Among other things, you offer training courses for physicians that include special operating room techniques, such as percutaneous spinal surgery for example. How did this specialization come to be?
Ostendorp: The backdrop for these courses was one physician’s realization that advanced training and continuing education in surgical techniques is very unsystematic and that surgeons at his hospital take a long time to learn a new minimally-invasive procedure for instance. This is why the learning curve of physicians was meant to be improved and time and effort as well as stress reduced at the same time. Initially, I looked at the procedure from a cognitive psychology perspective and searched for physicians who perform this procedure at a very high level and are the experts so to speak. I conducted structured interviews with these physicians and performed knowledge analyses. We found out that the discrepancies in surgical skills between the physicians are very significant – their skill levels ranged from that of a soccer player playing in a regional league to that of one playing in the major league as it were. All of the physicians who participated in the cognitive analysis enjoyed a high reputation among their peers. The differences in skill levels are unusual when all physicians share the same learning biography – medical degree, specialty training, and corresponding continuing education courses. This is why we designed advanced training courses together with surgeons and interventional physicians that focus on cognitive psychology as well as learning and educational science aspects.
One concrete example of this: a physician who checked whether the patient is properly positioned as it relates to the patient’s spine anatomy prior to performing a percutaneous spinal procedure has a significantly easier time during the surgery than a physician who didn’t check this positioning. The spine needs to be optimally positioned during C-arm imaging. Otherwise, the physician simply does not see enough on the X-ray. Yet the poorer the images are on the monitor which is influenced by the positioning, the more time the physician is going to need during the surgery to take X-rays. The length of X-radiation required by a physician who strives for the highest level of professionalism and one who is at a provisional plateau can range between 20 seconds and nine minutes for comparable patients. To a learning psychologist, this time difference is an indication that the skill level differs. Our job, therefore, is to identify this knowledge relevant to performance and operation and impart it in our courses to all physicians at the highest level possible.
The interview was conducted by Simone Ernst and translated by Elena O’Meara.