Computer Programming

Work System Analysis: The Key to Understanding Health Care Systems

Many articles in the medical literature state that medical errors are the result of systems problems, require systems analyses, and can only be addressed with systems solutions. Within that same body of literature is a growing recognition that human factors engineering methods and design principles are needed to reduce medical errors and, hence, increase patient safety. Work system analysis methods, which are based on industrial and human factors engineering tools, have much to contribute toward patient safety, specifically because of their focus on systems. They offer principles and methods for analyzing systems, which, if followed, should help health care administrators and clinicians properly analyze their units or facilities, and should lead to more robust patient safety interventions. In this paper, steps for executing a work system analysis are provided. To facilitate comprehension of the steps, the medication administration system is used as an example.

System analysis has much to contribute to patient safety, specifically through its study of organizational and work systems. In general, a system analysis yields an understanding of how a system works and how different elements in a system interact. This facilitates system design and system redesign, and aims to improve the interface between components of a system in order to enhance the functioning of each individual component in the overall system. Adopting a systems approach to error reduction requires a shift from blaming individuals for errors to analyzing systems to uncover design flaws, thus moving from addressing problems reactively (i.e., after problems occur) to proactively preventing accidents through system analysis and design.

Although many different methods have been used to conduct system analysis in industry, few methods have been widely used in health care. System analysis methodologies include, among others, the macroergonomic analysis and design (MEAD), 35, 36 fault tree analysis, 37, 38 failure modes and effects analysis (FMEA), 39, 40 health care failure modes and effects analysis (HFMEA), 41 and probabilistic risk assessment (PRA). 42, 43 Each of these methods uses similar principles to analyze and determine the weaknesses of the system and facilitate its redesign. In the remainder of this paper, the main steps that these methods share are identified and explained in detail.

Before presenting the main steps in a system analysis, an understanding of system terms must be developed. To facilitate reader comprehension of the terms and steps in the system analysis, the medication administration system will be used as an example throughout the remainder of the paper.

System element: A system element is anything that is part of a particular system. Elements can include people, technologies, policies, lighting, furniture, and jobs. In the case of the medication administration system, elements include the administering nurses, patients, medications, medication administration record (MAR), medication stock room, patient rooms, and identification bands.

System attribute: System attributes are the perceived characteristics of the system. The medication administration system attributes could include “error-free,” “time consuming,” “chaotic,” and “high quality.”

System boundary: System boundaries are zones between one system and another. These zones can be in time, space, process, or hierarchy.

Temporal boundary: A temporal boundary separates systems in time. For the medication administration system, a temporal boundary could be drawn between the first and second shift.

Spatial boundary: A spatial boundary separates systems in space. An example could be the medication administration system for one particular unit versus that of another unit.

Process boundary: A process boundary separates systems into adjacent component processes, also known as subprocesses. The medication use system contains component processes of ordering, transcribing, verifying, dispensing, administering, and documenting. An example of a process boundary might then be the boundary between the process of dispensing and delivering medications to the unit and the process of administering the medication.

Hierarchical boundary: A hierarchical boundary separates systems by their location in a hierarchy of systems. For example, the medication administration system exists within a larger system known as a unit. The unit exists within a larger system of a hospital. A hospital exists within a larger community health system.

System input: A system input is anything necessary to energize the system. For medication administration, inputs include nurses who administer drugs, drugs, MARs, physician orders, and pharmacy dispensing. These elements are inputs because they are necessary for medication administration to take place.

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