The mahogany door swung open. Aaron poked his head out. "Good to see you, Will. Come in. You are right on time for submitting your needs assessment. Impressive." Will turned his head and said, "Does this mean a bonus?" Marcia smiled at both and said I'll be right with you, I just need to make one more call. Aaron pulled Will aside, "So Will, before we start, tell me what you found." Will summarized, "The RBAs appear to be a prime example of an opportunity to improve both efficiency and quality of patient care through teamwork. Right now staff are confused about their roles and the effects of new technology such as the RBAs. There are specific steps which can be taken to improve RBA training, there are also overreaching issues which will impact the effectiveness of that training." Marcia hung up the phone, "I couldn't help overhearing your conversation. I'm looking forward to reading the specifics of your report.

Purpose of the Study

This report began as an analysis of a potential redesign of the training procedures related to the Robot Blood Analyzers (RBA's). This analysis revealed an opportunity for better achieving the hospital's need for efficient teams focused on quality care. This report provides a needs assessment that includes analysis of key issues and perspectives, goals, solutions, alternative solutions, and evaluation.

Process of Data Collection

The data came from interviews with Aaron Seymore, Mitch Huddleston, a supervising nurse, an RN, an LPN, a nursing assistant, a resident doctor, a chief resident, a surgical physician, Dr. Hamid Kasim, a medical technologist, a lab technician, Peter Britain and Gordy Marsalla of RoboMedic, patients and their families. The nature of several of these interviews was confidential and so specific references within this report will be anonymous. Documents regarding critical incidents involving the RBA, and lab reports of RBA TATs, were also consulted.

Key Issues and Perspectives

1. Communication of Corporate Philosophy

   Interviews with staff and patients indicate doubt regarding the compatibility of increased efficiency and quality patient care. For example, a staff doctor said, "We are all accountable to the bottom line so much these days, that sometimes I'm afraid we are forgetting what is best for our patients." Hospital personnel recognize that technology such as the RBAs produce results more quickly, yet there is a tendency to see this as a cost saving maneuver rather than a means of improving patient care. A nurse said in reference to the RBAs, "Money's the real bottom line around here now -- not patient care." There is a need for the hospital staff to embrace the dual corporate mission.

2. Teamwork

   The operational objectives include creating patient-centric care through the development of inter-service teams. However, many staff personnel complain about new roles and responsibilities. A medical lab technician has complained that he continually must train RBA users. An LPN has expressed resentment toward the lab technicians, "Do you think they would support us? No way. They are out for themselves." A medical technologist, confident about her competence, has complained about having to perform multiple roles, "Now they expect us to cover all of the other specialties as well as the one we trained for."

3. RoboMedic Vendor Service

   RoboMedic is an innovative company that has created a time and money saving machine. Hampstead provides the "beta testers" for the RoboMedic upgrades. RoboMedic stated that Hampstead was getting the highest quality service through installation of the latest updates of software. However, RoboMedic is improving its equipment so quickly that it cannot distribute updated information for reference by the end-users. The RoboMedic personnel communicate information of these upgrades and any end-user changes in procedure to the hospital IS staff and the lab technicians. The lab technicians pass along this information to the end-user hospital personnel.

4. Standardize RBA Training

   The training for the RBAs must be standardized. Installing upgrades as soon as they are available causes many problems. End-user staff are confused and frustrated by this policy. While it may seem more cost-efficient to use the hospital personnel most familiar with the RBAs for training; it is not. End-users complain of "attitudes" from technical personnel and about inconsiderate times for training. This produces outcomes not consistent with the goals of increased efficiency and improved patient care.

Goals and Solutions

1. Better Patient Care Through More Effective Teamwork:
   • Teamwork must be improved in order to meet the goal of improving quality patient care. Staff attitudes can improve through teamwork. Focus groups are a method to establish teamwork and employee empowerment. They aid decision making and allow teams to gain more responsibility. They will make decisions addressing individual roles within each team and decide what cross training is needed and which staff lines will be affected. Focus groups will include doctors, nurses, technicians and patients. In addition the teams will generate policies regarding technology, specifically RBA usage and methods of communicating these decisions. Implementation/training occurs within each team as opposed to position specific training (i.e. all technicians).

2. Recommended Non-training Solutions-Improve Service from RoboMedic:
   • Require liaison between RoboMedic and hospital concerning redesign of future software for RBAs. Since the software currently used is "one of the best", don't allow upgrades unless approved by the administration ( and instructional designer); if the upgrade seems necessary, then test it on one of the floors before installing it on all of the machines.

   • Use RoboMedic personnel as subject matter experts rather than as trainers. Their technical expertise is a barrier to effective communication with non-technical staff.

   • Promote the value of RBAs among the staff and advise RoboMedic to promote the value among the community in terms of quality patient care using RoboMedic research.

3. Assure Quality Standardized Training: The analysis of past RBA usage does not indicate if out of range readings are due to human error, technical problems, or unavoidable problems with blood samples. Standardized training and certification will provide assurance of proficiency.
   • Train in teams including all levels of nurses, CNAs, resident doctors, and lab technicians. Clarify roles for all concerned including the understanding that everyone is cross-trained for efficient patient care.

   • Retrain to demonstrate the correct procedures of the RBA conducted by "master performers" within the staff teams.

   • Develop tutorials so that all staff could practice on the multimedia computers.

   • Rewrite instructions included with RBA (new job aid).

   • Have training test that must be passed in order to use the RBA and provide a hospital certification to use the machine.

Recommended non-training Solutions:

• Promoting the concept of better communication and teams can be more effective if compensation and other rewards are aligned with the new hospital organization.

• Financially compensate staff for training sessions.

• Offer incentives for prompt and accurate posting of lab results and other duties (certificates, lunches, preferred parking spaces, picture on wall).

• Offer hospital sponsored social functions for teams.

• Have a suggestion/ complaint box which teams and administration can review.

Alternative Solutions (Not Recommended):

• Extensive teamwork workshops training to status quo. This would be an expensive program and would be an onerous burden which would create resentment instead of teamwork in staff. On the other hand, developing teamwork training for the specific purpose of improved performance with RBAs provides a model for teamwork in other areas and focuses on a specific technological training need.

• RBA training without emphasis on service teams. Unanticipated events and changes in hospital routines are common. In order to effectively solve problems staff need open lines of communication and an understanding of the abilities and responsibilities of co-workers.

• Total non-training solution: Although specific improvements such as improved RBA interface, improved job aid, compensation aligned with service team performance would improve quality of care, there is still a need for standardization of training with the RBAs. Several staff including a resident doctor and a nurse have expressed uncertainty about procedures for RBA use. New staff are trained in an ad hoc manner.

• Contract with a new RBA vendor with established training and a better quality record. This alternative is costly due to the infrastructure already established by RoboMedic. Many of the staff are already competent in the use of current RBAs; improved training and teamwork are preferable solutions.

Evaluation

1. Evaluation of Teams and Communication.
   • A goal of the recommended solution is better patient care through teamwork, evaluation should include team self-perception. This evaluation could be an additional benefit to the teams.

2. Evaluation of RBA Usage.
   • Currently RBA testing has a first try failure rate of 8 to 10 for every 325 uses. This statistic will provide a benchmark for formative evaluation of training. Currently data is not collected on the cause of the misreadings. A pilot study should be conducted in the initial training sessions to analyze the specific cause of out of range readings. Knowing whether failure is due to a poor blood sample, calibration of the machines, or improper data entry will be critical information for assessing the effectiveness of training.

   • If this evaluation points to human error in entering data due to poor interface design or other technical problems, the following long term solutions are recommended. These changes would only be implemented after testing with end users:
     • Include an error message that alerts users to a machine malfunction.
     • Provide a better back up system for the robots when power fails (battery power that saves and displays the results for immediate feedback).
     • Have robot automatically print a hard copy.
     • Redesign the RBA screen display to cut the chances of human error in entering the most important information (temperature and oxygen).
     • Provide embedded instruction with new design.

Two days later in Marcia's office...

Marcia got right to the point, "I've read your report, it seems that our teams are not working exactly as hoped." Will held his breath, he had agonized over his decision to present a report which was critical of Marcia's plans. Marcia continued, "You've presented an excellent model for getting us back on track. I've passed your report on to the corporate offices in Chicago. They want to meet with you on April 10, be ready for some tough questions."