Rsd3 jun2

Human Factors & Complex Systems Group Loughborough Design School

Complex multi-layered system maps Does zoom in/out interaction help for

better systems understanding?

Alfred Clatworthy Holmen Thomas Jun

Loughborough Design School Loughborough University, UK


Background

System/Process Maps

Soft system models

Hard system models

Real time system modelling

Object Oriented modelling

IDEF0

UML Influence diagrams Workflow models

Business process modelling

Cognitive Work Analysis

Data Flow Diagrams

State Transition Diagrams

IDEF3

Flowcharts Entity Relation Diagram

SysML


Mapping/Modelling allows us to

Identify complexity

Aid understanding

Improve communication

Basic elements of modelling methods

Nodes Links

Nodes

Hierarchical links

processcontentdiagrams

sub-task2

sub-task1

goal

Sequential links

flowchartsprocess

decision

start

statetransitiondiagrams

state1

state2

state3

Information links

communicationdiagrams

person1

person2

person3

data flowdiagrams

activity1

activity2datastorage

SequentiallinkInformation

link

Hierarchicallink

Activityview

Stakeholderview

Information/material

view


link

Hierarchicallink

Activityview

Stakeholderview


view


link

Hierarchicallink

stakeholderdiagram

informationdiagram

processcontentdiagram

group1

Activityview

Stakeholderview


view


link

Hierarchicallink

flowchart

swim laneactivitydiagram

statetransitiondiagram

group2

group3

Activityview

Stakeholderview


view


link

Hierarchicallink

communicationdiagram

group4

sequencediagram

Activityview

Stakeholderview


view


link

Hierarchicallink

data flowdiagram

IDEF0

group5

Activityview

Stakeholderview


view


link

Hierarchicallink

stakeholderdiagram

informationdiagram


data flowdiagram

IDEF0

flowchart




group1

group5

group4

group2

group3

sequencediagram


Study 1–Perceived ease of use and usefulness

Reality

Patient Discharge Processes

Activityview

Stakeholderview


view


link

Hierarchicallink

stakeholderdiagram

informationdiagram


data flowdiagram

IDEF0

flowchart




group1

group5

group4

group2

group3

sequencediagram

Healthcare workers

1. Stakeholder diagrams

2. Information diagrams

3. Process content diagrams

4. Flowcharts

5. Swim lane activity diagrams

6. State transition diagrams

7. Communication diagrams

8. Sequence diagrams

9. Data flow diagrams

10. IDEF0


Diagram Acceptance

PerceivedUsefulness

BehavioralIntentionto Use

PerceivedEase of Use

Technology Acceptance Model

(Davis, F.D., 1989)

Diagram Acceptance Model

Actual System

Use

Actual Diagram

Use

Findings

Ease of use

(Jun, G., et. al., 2010)

Usefulness

Findings

A single diagram cannot effectively capture the full

range of perspectives present in complex healthcare

State Transition Diagram

RealityAdult mental

health servicefor intake

and treatment

1 working dayTim

elin

eA

ctio

nO

u tco

me

Faci

litat

or

0-2weeks 2-4weeks

4 weeks-3 months

4-6 months7-12months

Referralreceived AssessmentAppointmentwith care co-ordinatorassigned

Formulation andagreement of treatment/careplan / riskmanagement / crisisplan

Interventionmenu:Introductionto serviceand CPAReviewof workingdiagnosis / needs/ goalsand initialtreatmentadviceFeedback to serviceuserand carerLiaisonwith otherservicesRiskassessment

T reatment / careplan / interventionimplemented

Interventionmenu:(Referto treatmentsub-menu)Pharmacological interventions, medication

management 'Wholelife'-employment/training/educationand leisure(social

inclusion), maintenanceof relationshipswith family

and friends.Carers' needsassessment, relapseplan,Information

aboutillness,WRAPSignposting to partneragencies.Management of financialand housingissues.

Casemanagementincludingcommissioning of care.

Psychologicaltreatmente.g.CBT,CAT

MDT CPAreview Discharge toprimary careorothercarepathway

AgreedtreatmentcompletedServiceusergoalsachievedLettersenttoserviceuser, GPand relevantotherssummarisingtreatment,progress,follow-up, relapseand crisisplan, primarycareplan and processto re-accesssecondary mental healthcare

Referraladministeredandassessmentbooked

Assessmentcompleted Firstavailablecareco-ordinator and /or consultantappointmentbooked

CPAfolder given toserviceuserCare plan withagreedgoals devised,signed byserviceuser.Serviceuserinformed ofdiagnosis and informationon illnessprovided.Referralsto otherservicesent.Risk managementplanreviewed

Medicalreviewandmedicationcoordinance

Psychologicalformulationcompletedand shared

with serviceuserand carer.Carers needsassessment completedand carer's

careplan devisedand implemented.Relapsepreventionand crisisplan agreed with

serviceusercarerand otheragencies. Copiesto

serviceuserand mental healthnotes.Serviceusergoalsre: employment / training /

education/ leisureachieved.Permanent safe and securehousing.Able to managefinancialissues.Accessing partneragenciesproviding specialist

helpe.g.businessforpeople, drug and alcohol

servicesTeammember Teammember Teammember Care co-ordinator,serviceuser,carer

Care co-ordinator,serviceuser,carerCare co-ordinator,serviceuser,carer

Care co-ordinator,serviceuser,carer

CPAupdated,signed by user.Discussionanddocumentationof user recoverygoals (thechangesrequiredfordischarge)incluserand carer'sview onhowthesecan beachieved

Recoverygoalsachieved.Goalsrequiringfurthertreatment identified.Care plan following discharge, relapsepreventionand crisisplan agreed, copygiven toserviceuserand placed inmental healthnotes.Lettersummarisingtreatment,progress,follow-upcare plansent toserviceuser,GPand others.Howto re-accesssecondary mentalhealth care.T ransfer/ transitionof care to otherservice/ pathway organised.Date ofreviewor follow-upsessione.g.CAT,CBTplanned. Repeatformaloutcome measures e.g. CORE,BDI

Continuetreatment

Care Pathway

Ely

Soham

Histon

Sawston

Melbourn

Gamlingay

CambridgeCity

NorthCam

SouthCam

Burwell

Geographic Map

Patient meets acare coordinator

AmI going to seeagain

Actionoutside the team(e.g. housing, etc)

Actioninside the team

Team supportwork

Adviceor Arrange to see patient

Otherprofessionals

Psychology

Medicalreview

Assessment- Psychologywork- Advice

Is someone else inI&T?

No

Yes

No

Yes

They get a newCare Coordinator

Discharge

R&R

Nothingworking

get better

Is anyotherservices going towork?

Yes

referDischarge

Acceptanceinto pathway

I&TAssessment

Not accepted

GPIAPT

Other servicee.g. CAMEO

Doctor assessespt (Mon/Thu,1hr)I&T teammeeting(Tue, 9.30)

No

referral (onlyOOH) Phone(urgent) Letteror fax

Assessmentschedule

(Acute)referralcomewith referralassessment(weekly)

List ofpatients &assessmenttypes

patient list

when mild,referral (tray)

GP

Acutecare

I&Tduty worker(sit by phone)9-4.30,

Mon-Fri

Gatewayworker

Adminscheduling

I&TreferralmeetingTue,9.00

IAPT

Patient

phoneappointment

Comewithclinicalinfo phoneappointment

Free Form Diagram

Organisation Diagram

C P FTAdult Services fo rCa m bridge

Rehab &Rec ove ry Services

C om plex Cases ServicesCAMEO (Early Interv e nti o nService)

Eating D is o rders Ser v ices

Liais o n P sychiatry Service

Gateway w o rkers

Acute care Services

Crisis Res o luti o nTea m (CRHTT)

In -patient w ardsC omm unityP sychiatric Nu rse*+

Doctor*

Occupati o nalTherapist* +

P sych o lo gist*

Supp o rt w o rker

S o cial w o rker* +

Alc o h o l Ser v ices

Ca m quit (St o p-smo kingService)

C o nsultants*

Intake &Treat me nt Services

Intake& Treatment(Cambridge No rth)Other Ser vices

N o rth

S o uth

* : Care Coordinator+: Duty Worker

Tea m ma nager

Tea m leader * +

S o cial Inclusi o nTeam

IA P T (I m pr ov ing Acess toP sych o lo gicalTherapies)

Whenurgent & OOHGP refer patient to acute care

Administrator arrangeassessment schedule

When Notaccepted into pathwayI&Tteam refer patient to suitable services

e.g. GP,IAPT,CAMEO,etc

P atient referredto IA P T

P atient referred toGateway w o rker

P atient referred to I&T team

P atient referred toacute care

P atient referred toduty w o rker

P atient assessed byGateway w o rker

WhenmildGateway worker passreferral to IAPT(tray)

P atient assessed by I&T team

Whenurgent & normal hourGP call patient to duty worker When not urgentGP referpatient to gatewayworker

P atient at the first meeting with a carecoo rdinat o r

P atient referred to R&R When more actions and monitoring are needed,

CCarrange furtheractions*

P atient discharged

WhenprolongedCCrefer patient to R&R

WhenrecoveredCCdischarge patient

Whenunclear

Administrator arrangeassessment schedule

Whenmoderateor severe

When accepted into pathway

I&Tteam designate care coordinator (CC)for patientCCarrange a meeting with patient

Whenmoderateor severeWhenmild

P atient referredto o ther ser v icesP atient under treat me nt

Care Coordinatoragree treatment / care plan / risk

management / crisisplan with patientand arrange treatment

Pati ent stat eswi thin I&T

T ransitionconditionT ransition actions

Pati ent stat esou tsid e of I&T

P atient at GP

P atient discussed at MDT meeting

When patients get worse,uncertain or recovered

CC discuss patients at weekly MDTmeeting

When more actions and monitoringare needed

CCreview progressand arran ge further actions**Further actions-medication management-psychologicaltreatment-carers'needs assessment-managementof financialandhousing issues

Whenhome treatment orward admission isneeded

Whendischarged,but follow-upis neededP atient at o therservices

Whenspecific needsGateway worker recommendsother suitable services

State Transition Diagram

Communication Diagram

When urgent &OOH, enquiry(phone call)When urgent&normal hour ,enquir y (phone call)

When not urgent,referral (letter or fax)

Assessme ntsc hedule

Assessme ntre sults

When se rious ,referral (phone)

Referral &assessme nt re sults

Li st of patient s &assessme nt types

Li st of patient s &assessme nt types

When mild,referral (tray)

Externalstakeholders

Stakeholder sin I&T

report

Referral

GP

Acute care

D uty w o rker

Gatewayw o rker

MDT tea m(weekly

meeting)

Schedulingad m in

I&Treferral team

I&Tassess me nt

team

IA P T

Carecoo rdinat o r

GP

R&R

Disc hargeletter

conditi oninformation

IAP T: Impro ving Acce ss to P sychological Therapy

I& T: Intake and TreatmentR&R: Rehab and Reco ve ryMD T: Multidi sc iplinar y Te am

deci sion

Otherpr o fessi o nals

in team

Otherpr o fessi o nalso utside team

referrals

referrals

report

report

referrals

referrals

Otherservices

Whenspecificneeds

GP referpatientto Gatewayworker

Getassessment

I&Tteamassesspatient

Agree withcare plan

Receiveinfoon carecoordinator

Gateway workerassess patient

Gateway workerrefer pt to I&T I&Tteamdesignate carecoordinator

Care Coordinatorcontact patient

CCdevelopcare plan

CCinformcare plan

Seeprofessionalsas referred by CC

MDT decidenext step

Carecoordinatorsee patient

P hysicalEvidence

ServiceUserActi o ns

VisibleC o ntactServiceP rov iderActi o ns

In v isibleC o ntactServiceP rov iderActi o ns

Supp o rtP ro cesses

Gateway workercontact patient

Receivereferral info

is informed ofthe next step

I&Tclinic

I&Twaitingroom

I&Treception

I&Twebsite

CCreferpt tonecessaryactions

Referredprofessionalseepatients

CCreportpt to MDT

CCmonitorpt progress

CC:Care CoordinatorMDT: MultidisciplinaryTeam

Service Blueprint

Study II – Choice and Usage

Healthcare workers

Adult mental health service

for intake and treatment


Study II – Choice and usage

Diagram Choice and Usage Model


Choice to usecertain diagrams

Actual use ofcertain diagrams

PerceivedUsefulness

DiagramCharacteristics

SocialInfluence

FacilitatingConditions

IndividualDifferences

(Adjusted from Venkatesh, V., 2008)




c

PerceivedUsefulness

Participant’scommunication style(visual/non-visual)

Diagram’s relevanceto issues discussed

Diagram’s consistencywtih participant’s

mental models

Participant’sfamiliarity wtihreal pathways

Individual Differences

Diagram Characteristics

(Jun, G., under review)

Study III - Workshops

Reality

Safer Medicine

Management Pathways

Hospitals

General practices

District nurses

Community pharmacies

Hospital pharmacies

Social care workers

Voluntary services

(e.g. AgeUK, EPP* )

Ambulances

Drugcompanies

Equipmentsuppliers

Distributors

Medical device agency

Rehap services

Medicinecontrol agency

Backstagecommunication

Frontstagecommunication

Patients

Phone

PostFax

Internet

@

NHS email

Phone

emisweb

pharmacyIT system

Hospitalpatient record

Care agency workers

IAS

Family & friends

Visiting books

- Patient takes medicine

Patient with low on medicine

When patient/carer does it him/herself- Patient/carer fills in the repeat prescription slip- Patient/carer drops the repeat prescription slip at GP (visit/call?)- Patient/carer collects repeat prescription (within 48 hrs?)- Patient/carer drops repeat prescription to pharmacy

When pharmacy has agreed to act on behalf of patient (prescription collection service)- Pharmacy contacts patient (every patient?)- Pharmacy fills in the repeat prescription slip- Pharmacy drops the repeat prescription slip to GP- Pharmacy collects a repeat prescription from GP

Patient at home with sufficient medicine

New (repeat) prescription at pharmacy

Patient admittedto hospital

When patient needs hospital care- Patient goes to hospital- Patient takes own medicine to hospital (?)

When patient ready to go home- Hospital discharges patient- Hospital provides medicine for 0/2/4 weeks? - Hospital informs GP and pharmacy?

- Pharmacy checks prescription- Pharmacy contacts GP for enquiry (if required)- Pharmacy dispenses medicine

Patient seen by GP or nurse

When patient has appointment at GP- Patient visits GP

When no change in medicine- Patient goes home

When need for medicine change- GP issues prescription- GP calls pharmacy (?)

- Patient drops it to pharmacy

When pharmacy offers delivery and patient chooses to get it- Pharmacy delivers medicine to patient's home

Otherwise- Patient/carer collects medicine

Patient at home with sufficient medicine(over 4 medicines)

Medicine dispensed (ready to be collected)


Issues

Not enough time for systems mapping

Inconsistent and uneven participation

Potential of using online engagement

How to present complex system maps?

Open IDEO

http://www.nhscitizen.org.uk/

Study IV- Interactive zoom in/out

Reality

Patient Discharge Processes

20 students

Zoom in/out

Ward

HospitalPharmacy

Central record

Home,Nursing/care home,

Interim beds

Transitionalcare team

GPs(pt’s, facility’s)

1. Assessment notification (Fax1)[pt detail, reason for transition care]

2. Assessment notification (Fax2)[discharge date]

3. Assessment notification (Fax2)[confirmation, name of carer]

4. dischargesummary

5. TTOmedicine

7. dischargesummary

7. discharge summary6. discharge summary

6. TTO medicine

6. patient

5. dischargesummary

Nurse Multidisciplinaryteam

Doctor(SHO, HO)

Wardpharmacist

Pharmacytechnician

Wardclerk

0. TransitionalCare needed

1.1 dischargedate 1.1 discharge

date

3.1 draftdischargesummary

3.2 confirmeddischargesummary

4. dischargesummary

5. TTOmedicine

NurseMedicinestorage

7. dischargesummary

Ward

5. 1 TTOmedicine

5. 1dischargesummary


5. 1 TTOmedicine

6.1 dischargesummary

HospitalPharmacy

Central record


Interim beds



5. TTOmedicine

7. dischargesummary

7. dischargesummary

6. discharge summary

6. TTO medicine

5. dischargesummary

NurseM ultidisciplina ry

teamDoctor

(SH O, H O)

Wardpha rmacist

Pha rma cytechnician

Wardcle rk



date


dischargesummary

NurseM edicinestorage

5. 1 TTOmedicine



5. 1 TTOmedicine

summary


Hospital

Pharmacy

Central record


Interim beds



5. TTOmedicine

7. dischargesummary

7. dischargesummary

6. discharge summary

6. TTO medicine

5. dischargesummary

NurseM ultidisciplina ry

teamDoctor

(SH O, H O)

Wardpha rmacist

Pha rma cytechnician

Wardcle rk



date


dischargesummary

NurseM edicinestorage

5. 1 TTOmedicine



5. 1 TTOmedicine

summary


Ward

HospitalPharmacy

Central record


Interim beds



1. Assessment notification (Fax1)[pt detail, reason for transition care]

2. Assessment notification (Fax2)[discharge date]

3. Assessment notification (Fax2)[confirmation, name of carer]

4. dischargesummary

5. TTOmedicine

7. dischargesummary

7. discharge summary6. discharge summary

6. TTO medicine

6. patient

5. dischargesummary

Nurse Multidisciplinaryteam

Doctor(SHO, HO)

Wardpharmacist

Pharmacytechnician

Wardclerk



date


3.2 confirmeddischargesummary

4. dischargesummary

5. TTOmedicine

NurseMedicinestorage

7. dischargesummary

Ward

5. 1 TTOmedicine



5. 1 TTOmedicine

6.1 dischargesummary

Evaluation – Performance and preference

Time taken till participants felt they had a

good understanding of the map contents

Usability - Questionnaire Easily understandable (ease of use)

Helpful in understanding and communicating how

the system works (usefulness)

Enjoyable to use the map

Semi-structured interviews


Results - Time

Ave Std Max Min

Zoom in/out interaction

6 min 57 sec 55 sec 8 min

56 sec 5 min 52 sec

No interactions

7 min 27 sec 49 sec 8 min

54 sec 6 min 12 sec

Results - Questionnaire

1. Easily understandable

2. Helpful in better understanding and

communicating

3. Enjoyable

0

2

4

6

8

10

Strongly Agree Agree Neutral Disagree StronglyDisagree

Zoom in/out interaction No interaction

0

2

4

6

8

10

Strongly Agree Agree Neutral Disagree StronglyDisagree

0

2

4

6

8

10

StronglyAgree

Agree Neutral Disagree StronglyDisagree


Results- Interviews

Positive Negative Etc

Zoom in/out interaction

Fun and easy Interesting

Daunting and overwhelming Hard to control

Top-down vs bottom-up Clearer instruction

No interactions

Easy and useful

Complicated, unclear and overwhelming

Better use of colour


Conclusion

Interactive zoom in/out map took less time in

understanding

Interactive zoom in/out map was rated better in

the interview (more fun)

However, little difference between them in

terms of perceived ease of use and usefulness





Actual use ofcertain diagrams

PerceivedUsefulness


SocialInfluence



(Venkatesh, V., 2008)

Perceived Fun?


Thank You!

Alfred Clatworthy Holmen Thomas Jun, [email protected] Loughborough Design School Loughborough University, UK

Activityview

Stakeholderview


view


link

Hierarchicallink

stakeholderdiagram

informationdiagram


data flowdiagram

IDEF0

flowchart




group1

group5

group4

group2

group3

sequencediagram



PerceivedUsefulness


SocialInfluence



Documents

Rsd3 jun2