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1.  Packages of participation: Swedish employees’ experience of Lean depends on how they are involved 
Background
Lean Production is a dominant approach in Swedish and global manufacturing and service industries. Studies of Lean’s employee effects are few and contradictory.
Purpose
Employee effects from Lean are likely not uniform. This paper investigates the effect of employees' participation on their experiences of Lean.
Method
This study investigated how different packages of employee participation in Lean affected manufacturing workers’ experiences of Lean. During 2008–2011, qualitative and quantitative data were collected from Swedish manufacturing companies participating in the national Swedish Lean Production program Produktionslyftet. Data from 129 surveys (28 companies), 39 semi-structured interviews, and 30 reports were analyzed. In the main analysis, comparisons were made of the survey-reported Lean experiences of employees in three groups: temporary group employees (N = 36), who participated in Lean mostly through intermittent projects; continuous group employees (N = 69), who participated through standing improvement groups; and combined group employees (N = 24), who participated in both ways.
Results
Continuous group employees had the most positive experience of Lean, followed by the combined group. Temporary group employees had the least positive experiences, being less likely than their counterparts to report that Lean improved teamwork, occupational safety, and change-related learning, decision making, and authority.
Conclusions
These findings support the importance of continuous, structured opportunities for participation but raise the possibility that more participation may result in greater workload and role overload, mitigating some benefits of employee involvement. Consequently, companies should consider involving employees in change efforts but should attend to the specific design of participation activities.
doi:10.1080/21577323.2012.729001
PMCID: PMC3962014  PMID: 24665370
Organizational human factors; macroergonomics; Organizational change; Job design; Quality of working life; Lean Production
2.  Modeling nurses' acceptance of bar coded medication administration technology at a pediatric hospital 
Objective
To identify predictors of nurses' acceptance of bar coded medication administration (BCMA).
Design
Cross-sectional survey of registered nurses (N=83) at an academic pediatric hospital that recently implemented BCMA.
Methods
Surveys assessed seven BCMA-related perceptions: ease of use; usefulness for the job; social influence from non-specific others to use BCMA; training; technical support; usefulness for patient care; and social influence from patients/families. An all possible subset regression procedure with five goodness-of-fit indicators was used to identify which set of perceptions best predicted BCMA acceptance (intention to use, satisfaction).
Results
Nurses reported a moderate perceived ease of use and low perceived usefulness of BCMA. Nurses perceived moderate-or-higher social influence to use BCMA and had moderately positive perceptions of BCMA-related training and technical support. Behavioral intention to use BCMA was high, but satisfaction was low. Behavioral intention to use was best predicted by perceived ease of use, perceived social influence from non-specific others, and perceived usefulness for patient care (56% of variance explained). Satisfaction was best predicted by perceived ease of use, perceived usefulness for patient care, and perceived social influence from patients/families (76% of variance explained).
Discussion
Variation in and low scores on ease of use and usefulness are concerning, especially as these variables often correlate with acceptance, as found in this study. Predicting acceptance benefited from using a broad set of perceptions and adapting variables to the healthcare context.
Conclusion
Success with BCMA and other technologies can benefit from assessing end-user acceptance and elucidating the factors promoting acceptance and use.
doi:10.1136/amiajnl-2011-000754
PMCID: PMC3534453  PMID: 22661559
Bar coded medication administration systems; BCMA; technology acceptance; TAM; implementation science; pediatric hospital; human factors
3.  Pharmacy workers’ perceptions and acceptance of bar coded medication technology in a pediatric hospital 
Background
The safety benefits of bar-coded medication dispensing and administration technology (BCMA) depend on its intended users favorably perceiving, accepting, and ultimately using the technology.
Objectives
(1) To describe pharmacy workers’ perceptions and acceptance of a recently implemented BCMA system and (2) to model the relationship between perceptions and acceptance of BCMA.
Methods
Pharmacists and pharmacy technicians at a Midwest US pediatric hospital were surveyed following the hospital’s implementation of a BCMA system. Twenty-nine pharmacists and ten technicians’ self-reported perceptions and acceptance of the BCMA system were analyzed, supplemented by qualitative observational and free-response survey data. Perception-acceptance associations were analyzed using structural models.
Results
The BCMA system’s perceived ease of use was rated low by pharmacists and moderate by pharmacy technicians. Both pharmacists and technicians perceived that the BCMA system was not useful for improving either personal job performance or patient care. Pharmacy workers perceived that individuals important to them encouraged BMCA use. Pharmacy workers generally intended to use BCMA but reported low satisfaction with the system. Perceptions explained 72% of the variance in intention to use BCMA and 79% of variance in satisfaction with BCMA.
Conclusions
To promote their acceptance and use, BCMA and other technologies must be better designed and integrated into the clinical work system. Key steps to achieving better design and integration include measuring clinicians’ acceptance and elucidating perceptions and other factors that shape acceptance.
doi:10.1016/j.sapharm.2012.01.004
PMCID: PMC3390462  PMID: 22417887
bar coded medication dispensing and administration systems; BCMA; technology acceptance; pediatric hospital
4.  Social and personal normative influences on healthcare professionals to use information technology: Towards a more robust social ergonomics 
Theoretical issues in ergonomics  2011;13(5):546-569.
Social structures and processes are increasingly acknowledged and studied within the human factors/ergonomics (HFE) discipline. At the same time, social phenomena are rarely the focus of HFE work, leaving a knowledge gap. The present study directly addresses social and personal normative forces that influence technology use and performance. Social and personal normative influence to use electronic health records (EHR) were investigated using semi-structured qualitative interviews with 20 attending physicians at two US hospitals. Analyses used a comprehensive framework based on leading social scientific theories and revealed numerous sources of influence, including hospital administration, colleagues, patients, clinical and professional groups, government, and one’s self. Influence was achieved through different means and invoked different psychological processes. Findings motivate a new view of professionals’ technology use as a highly social process occurring in a social context, with implications for research, policy, design, and in general the development of a robust social ergonomics.
doi:10.1080/1463922X.2010.549249
PMCID: PMC3467107  PMID: 23066349
social ergonomics; sociotechnical systems; social influence; electronic health records; healthcare
5.  What stands in the way of technology-mediated patient safety improvements? A study of facilitators and barriers to physicians' use of electronic health records 
Journal of patient safety  2011;7(4):193-203.
Objectives
For electronic health records (EHR) systems to have a positive impact on patient safety, clinicians must be able to use these systems effectively after they are made available. This study's objective is to identify and describe facilitators and barriers to physicians' use of EHR systems.
Methods
Twenty research interviews were conducted with attending physicians who were using EHR at one of two Midwest community hospitals and/or at their respective outpatient clinics.
Results
Analyses yielded over 200 perceived facilitators and barriers, comprising 19 distinct categories. Categories of facilitators/barriers related to user attributes included learning, typing proficiency, understanding the EHR system, motivation/initiative, and strategies/workarounds. Categories related to system attributes were supporting hardware/software and system speed, functionality, and usability. Categories related to support from others were formal technical support, formal training, and informal support from colleagues. Categories of organizational facilitators/barriers were time allowance and inter-institutional integration. Categories of environmental facilitators/barriers were physical space, electricity, wireless connectivity, and the social environment.
Conclusion
Together, the broad set of discovered facilitators and barriers confirms and expands prior research on the facilitators and barriers to health information technology use. The depth of reported information on each facilitator and barrier made possible by qualitative interview methods contributes to the theoretical understanding of facilitators and barriers to EHR use. Equally as important, this study provides an information base from which relevant policy and design interventions can be launched in order to improve the use of EHR systems and, thus, patient safety.
doi:10.1097/PTS.0b013e3182388cfa
PMCID: PMC3220192  PMID: 22064624
6.  THE TECHNOLOGY ACCEPTANCE MODEL: ITS PAST AND ITS FUTURE IN HEALTH CARE 
Increasing interest in end users’ reactions to health information technology (IT) has elevated the importance of theories that predict and explain health IT acceptance and use. This paper reviews the application of one such theory, the Technology Acceptance Model (TAM), to health care. We reviewed 16 data sets analyzed in over 20 studies of clinicians using health IT for patient care. Studies differed greatly in samples and settings, health ITs studied, research models, relationships tested, and construct operationalization. Certain TAM relationships were consistently found to be significant, whereas others were inconsistent. Several key relationships were infrequently assessed. Findings show that TAM predicts a substantial portion of the use or acceptance of health IT, but that the theory may benefit from several additions and modifications. Aside from improved study quality, standardization, and theoretically motivated additions to the model, an important future direction for TAM is to adapt the model specifically to the health care context, using beliefs elicitation methods.
doi:10.1016/j.jbi.2009.07.002
PMCID: PMC2814963  PMID: 19615467
Technology use; behavior; health information technology; technology acceptance model
8.  That’s nice, but what does IT do? Evaluating the impact of bar coded medication administration by measuring changes in the process of care 
Health information technology (IT) is widely endorsed as a way to improve key health care outcomes, particularly patient safety. Applying a human factors approach, this paper models more explicitly how health IT might improve or worsen outcomes. The human factors model specifies that health IT transforms the work system, which transforms the process of care, which in turn transforms the outcome of care. This study reports on transformations of the medication administration process that resulted from the implementation of one type of IT: bar coded medication administration (BCMA). Registered nurses at two large pediatric hospitals in the US participated in a survey administered before and after one of the hospitals implemented BCMA. Nurses’ perceptions of the administration process changed at the hospital that implemented BCMA, whereas perceptions of nurses at the control hospital did not. BCMA appeared to improve the safety of the processes of matching medications to the medication administration record and checking patient identification. The accuracy, usefulness, and consistency of checking patient identification improved as well. In contrast, nurses’ perceptions of the usefulness, time efficiency, and ease of the documentation process decreased post-BCMA. Discussion of survey findings is supplemented by observations and interviews at the hospital that implemented BCMA. By considering the way that IT transforms the work system and the work process a practitioner can better predict the kind of outcomes that the IT might produce. More importantly, the practitioner can achieve or prevent outcomes of interest by using design and redesign aimed at controlling work system and process transformations.
doi:10.1016/j.ergon.2011.02.007
PMCID: PMC3113497  PMID: 21686318
health information technology; bar coded medication administration; process change; patient safety; human factors engineering
9.  How does lean work in emergency care? A case study of a lean-inspired intervention at the Astrid Lindgren Children's hospital, Stockholm, Sweden 
Background
There is growing interest in applying lean thinking in healthcare, yet, there is still limited knowledge of how and why lean interventions succeed (or fail). To address this gap, this in-depth case study examines a lean-inspired intervention in a Swedish pediatric Accident and Emergency department.
Methods
We used a mixed methods explanatory single case study design. Hospital performance data were analyzed using analysis of variance (ANOVA) and statistical process control techniques to assess changes in performance one year before and two years after the intervention. We collected qualitative data through non-participant observations, semi-structured interviews, and internal documents to describe the process and content of the lean intervention. We then analyzed empirical findings using four theoretical lean principles (Spear and Bowen 1999) to understand how and why the intervention worked in its local context as well as to identify its strengths and weaknesses.
Results
Improvements in waiting and lead times (19-24%) were achieved and sustained in the two years following lean-inspired changes to employee roles, staffing and scheduling, communication and coordination, expertise, workspace layout, and problem solving. These changes resulted in improvement because they: (a) standardized work and reduced ambiguity, (b) connected people who were dependent on one another, (c) enhanced seamless, uninterrupted flow through the process, and (d) empowered staff to investigate problems and to develop countermeasures using a "scientific method". Contextual factors that may explain why not even greater improvement was achieved included: a mismatch between job tasks, licensing constraints, and competence; a perception of being monitored, and discomfort with inter-professional collaboration.
Conclusions
Drawing on Spear and Bowen's theoretical propositions, this study explains how a package of lean-like changes translated into better care process management. It adds new knowledge regarding how lean principles can be beneficially applied in healthcare and identifies changes to professional roles as a potential challenge when introducing lean thinking there. This knowledge may enable health care organizations and managers in other settings to configure their own lean program and to better understand the reasons behind lean's success (or failure).
doi:10.1186/1472-6963-12-28
PMCID: PMC3298466  PMID: 22296919
10.  A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life 
BMJ quality & safety  2011;20(1):15-24.
Backgrounds
Nursing workload is increasingly thought to contribute to both nurses’ quality of working life and quality/safety of care. Prior studies lack a coherent model for conceptualizing and measuring the effects of workload in health care. In contrast, we conceptualized a human factors model for workload specifying workload at three distinct levels of analysis and having multiple nurse and patient outcomes.
Methods
To test this model, we analyzed results from a cross-sectional survey of a volunteer sample of nurses in six units of two academic tertiary care pediatric hospitals.
Results
Workload measures were generally correlated with outcomes of interest. A multivariate structural model revealed that: the unit-level measure of staffing adequacy was significantly related to job dissatisfaction (path loading = .31) and burnout (path loading = .45); the task-level measure of mental workload related to interruptions, divided attention, and being rushed was associated with burnout (path loading = .25) and medication error likelihood (path loading = 1.04). Job-level workload was not uniquely and significantly associated with any outcomes.
Discussion
The human factors engineering model of nursing workload was supported by data from two pediatric hospitals. The findings provided a novel insight into specific ways that different types of workload could affect nurse and patient outcomes. These findings suggest further research and yield a number of human factors design suggestions.
doi:10.1136/bmjqs.2008.028381
PMCID: PMC3058823  PMID: 21228071
workload; mental workload; patient safety; medication error; quality of working life
11.  Effects of mental demands during dispensing on perceived medication safety and employee well being: A study of workload in pediatric hospital pharmacies 
Background
Pharmacy workload is a modifiable work system factor believed to affect both medication safety outcomes and employee outcomes such as job satisfaction.
Objectives
This study sought to measure the effect of workload on safety and employee outcomes in two pediatric hospitals and to do so using a novel approach to pharmacy workload measurement.
Methods
Rather than measuring prescription volume or other similar indicators, this study measured the type and intensity of mental demands experienced during the medication dispensing tasks. The effects of external (interruptions, divided attention, rushing) and internal (concentration, effort) task demands on perceived medication error likelihood, adverse drug event likelihood, job dissatisfaction, and burnout were statistically estimated using multiple linear and logistic regression.
Results
Pharmacists and pharmacy technicians reported high levels of external and internal mental demands during dispensing. The study supported the hypothesis that external demands (interruptions, divided attention, rushing) negatively impacted medication safety and employee well being outcomes. However, as hypothesized, increasing levels of internal demands (concentration and effort) were not associated with greater perceived likelihood of error, adverse drug events, or burnout, and even had a positive effect on job satisfaction.
Conclusion
Replicating a prior study in nursing, this study shows that new conceptualizations and measures of workload can generate important new findings about both detrimental and beneficial effects of workload on patient safety and employee well being. This study discusses what those findings imply for policy, management, and design concerning automation, cognition, and staffing.
doi:10.1016/j.sapharm.2009.10.001
PMCID: PMC3052977  PMID: 21111387
Workload; mental demands; medication error; safety; employee well being; human factors
12.  People or systems? To blame is human. The fix is to engineer 
Professional safety  2009;54(12):34-41.
Person-centered safety theories that place the burden of causality on human traits and actions have been largely dismissed in favor of systems-centered theories. Students and practitioners are now taught that accidents are caused by multiple factors and occur due to the complex interactions of numerous work system elements, human and non-human. Nevertheless, person-centered approaches to safety management still prevail. This paper explores the notion that attributing causality and blame to people persists because it is both a fundamental psychological tendency as well as an industry norm that remains strong in aviation, health care, and other industries. Consequences of that possibility are discussed and a case is made for continuing to invest in whole-system design and engineering solutions.
PMCID: PMC3115647  PMID: 21694753
13.  Cognitive performance-altering effects of electronic medical records: An application of the human factors paradigm for patient safety 
According to the human factors paradigm for patient safety, health care work systems and innovations such as electronic medical records do not have direct effects on patient safety. Instead, their effects are contingent on how the clinical work system, whether computerized or not, shapes health care providers' performance of cognitive work processes. An application of the human factors paradigm to interview data from two hospitals in the Midwest United States yielded numerous examples of the performance-altering effects of electronic medical records, electronic clinical documentation, and computerized provider order entry. Findings describe both improvements and decrements in the ease and quality of cognitive performance, both for interviewed clinicians and for their colleagues and patients. Changes in cognitive performance appear to have desirable and undesirable implications for patient safety as well as for quality of care and other important outcomes. Cognitive performance can also be traced to interactions between work system elements, including new technology, allowing for the discovery of problems with “fit” to be addressed through design interventions.
doi:10.1007/s10111-010-0141-8
PMCID: PMC3072581  PMID: 21479125
Human factors; health information technology; electronic medical records; patient safety; cognitive work performance
14.  PHYSICIANS' BELIEFS ABOUT USING EMR AND CPOE: IN PURSUIT OF A CONTEXTUALIZED UNDERSTANDING OF HEALTH IT USE BEHAVIOR 
Purpose
To identify and describe physicians' beliefs about use of electronic medical records (EMR) and computerized provider order entry (CPOE) for inpatient and outpatient care, to build an understanding of what factors shape information technology (IT) use behavior in the unique context of health care delivery.
Methods
Semi-structured qualitative research interviews were carried out, following the beliefs elicitation approach. Twenty physicians from two large Midwest US hospitals participated. Physicians were asked questions to elicit beliefs and experiences pertaining to their use of EMR and CPOE. Questions were based on a broad set of behavior-shaping beliefs and the methods commonly used to elicit those beliefs.
Results
Qualitative analysis revealed numerous themes related to the perceived emotional and instrumental outcomes of EMR and CPOE use; perceived external and personal normative pressure to use those systems; perceived volitional control over use behavior; perceived facilitators and barriers to system use; and perceptions about the systems and how they were implemented. EMR and CPOE were commonly believed to both improve and worsen the ease and quality of personal performance, productivity and efficiency, and patient outcomes. Physicians felt encouraged by employers and others to use the systems but also had personal role-related and moral concerns about doing so. Perceived facilitators and barriers were numerous and had their sources in all aspects of the work system.
Conclusion
Given the breadth and detail of elicited beliefs, numerous design and policy implications can be identified. Additionally, the findings are a first step toward developing a theory of health IT acceptance and use contextualized to the unique setting of health care.
doi:10.1016/j.ijmedinf.2009.12.003
PMCID: PMC2821328  PMID: 20071219
electronic medical records; computerized provider order entry; beliefs elicitation; theory of planned behavior

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