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A Proactive Learning Approach to Building Adaptative Capacity During COVID-19: A Radiology Case Study
Event Type
Poster Presentation
TimeThursday, April 152:00pm - 3:00pm EDT
LocationHospital Environments
DescriptionBackground
The ongoing COVID-19 pandemic is an unprecedented event that has caught organizations by surprise. In general, there were few to no ready protocols, norms, standards, or guidelines to prepare for a relatively sudden event of this nature on such a large scale. Hospitals, in particular, have been severely strained for resources by the surge in patient visits and hospitalizations resulting from the novel infection, as well as the increased risk of comorbidities. Further, the ability of healthcare organizations to respond has been challenged by the lack of, or ambiguity around information related to the virus, infection rates, effectiveness of preventative measures (e.g. use of masks). Hospitals, therefore, have had to constantly adapt and make decisions on a unique set of situations under uncertainty, variability and time pressure in order to sustain operations and keep patients safe.
The purpose of this presentation is to describe a study which explored how the radiology unit of a large children’s hospital has adapted to the pandemic challenge. The study used a resilience engineering (RE) approach of identifying informal and formal adjustments, workarounds, innovations and other instantiations of adaptations in the unit. The study demonstrates the use of a novel tool that allows caregivers to self-report narratives of successful adaptation. The findings have implications for hospitals to learn from their own adaptive processes on the frontlines of care and inform strategic decisions at leadership levels to better enable the capabilities that underpin the organization’s resilience.

Methods
The Resilience Engineering Tool to Improve Patient Safety (RETIPS) is a semi-structured questionnaire consisting of narrative-based questions and multiple-choice questions (see Hegde et al. 2019 for a full description) aimed at eliciting examples of successful adaptations in everyday work. Questions are also designed to probe the types of challenges faced, factors that enabled success, and resources used. Demographic information, such as years of experience and the area of specialization, is also collected. A previous version of RETIPS was adapted for the purpose of the current study based on a review and feedback by radiologists and experts in human factors and resilience engineering. The questions, cognitive probes and response-choices were revised in order to focus on adaptations related to the COVID-19 pandemic and were tailored to the radiology context. The tool was made available via Google Forms to all employees in on [July 29th, 2020] and the majority of the responses were received over the next 10 weeks. The study and the tool were announced by direct emails to the department, posters, and face to face recruitment.
The responses, produced in a spreadsheet format, were organized into rows of text for qualitative data analysis. The narrative responses were coded by a team of 4 coders to identify themes relating to resilience. The data were divided into two halves and the coding tasks were distributed such that 1 primary coder and 1 secondary coder were assigned to each half of the dataset. The coding process was done in two 'runs’: i) Thematic Coding: to identify a set of themes and sub-themes relating to ; and ii) Strategies and Tactics: to identify specific ‘strategies’ and ’tactics’ used by the unit to address key challenges and issues.

Results
Fifty-six reports were received between July 29th and October 12th 2020 and included in the analysis. Participants’ roles included radiology leadership (21%), technologist (19%), nursing (13%), radiologists (10%), and sedation/anesthesia (10%). Participants described lessons-learned, and indicated the success factors, challenges, and resources pertinent to their examples. Participants reported responses to the following multiple-choice questions included:
“What were some of the challenges/concerns that prompted the response?”: uncertainty or ambiguity in the situation (58% of participants), perceived risk of infection (42%), patient condition or behavior (30.9%), communication issues with staff or patient (29%)
“What resources were necessary or helpful in this situation”: PPE (62% of participants), hospital-provided information (60%), co-workers and consults (53%)
“What area of specialty does the example relate to?”: radiology nursing (31%), radiology leadership (16%), radiologists (15%), sedation/anesthesia and other nursing (31%).
Thematic analysis of the narrative responses identified several themes that enabled caregivers and staff to adapt successfully, including:
o Communication of change: mention of information dissemination mechanisms (email, town hall, huddle, other forms of briefing) for policy or procedural change
o Knowing where to find resources: indication that information or resources were sought out and retrieved rather than waiting for them to be pushed to the participant
o Culture and attitudes: indication of the nature and mindset of individuals the respondent encountered in their narrative
o Timeliness and clarity of information: mention of the time frame information from leadership or higher is provided or the clarity of the message
o Leadership: direct mention of supervisor or beyond roles relative to the respondent
o Cooperation between coworkers: indication that shared workload, or collaboration is occurring
Additionally, the strategies identified included
o Interdepartmental cooperation: sharing of information and resources between hospital departments helped coordinate workflows hospital-wide.
o Shared understanding and awareness: developing shared mental models of workflows and expectations across individuals, units and teams.
o Availability and utilization of resources: the fact that necessary resources (e.g. PPE) were available when needed and used.
o Accountability: the fact that people followed appropriate protocols
o Availability of policies and procedures: information and resources to implement appropriate policies and procedures.

Application
Initial results were reported to the leadership of the radiology department on November 19th, 2020. The primary focus of the reporting was to introduce the leaders to the concepts of resilience engineering, provide initial feedback on COVID response to date, and suggestions for continued success based on findings. Our reporting had immediate impact in that the leadership encouraged continuous availability of the RETIPS tool and revolving analysis as a means for the hospital’s learning of its pandemic response. The healthy response rate to RETIPS demonstrates the feasibility of the tools as a means for organizational learning in healthcare – during the pandemic and beyond. During their review of the reports, the hospital leadership also commented that identification of effective adaptive strategies on the frontlines could inform new interventions beyond the standard approach to quality and safety of care. The presentation will expand on the above findings and discuss how these could be translated into actionable policies and interventions.