Patient Safety Learning Lab at Dartmouth-Hitchcock Medical Center
Command & Control
Facilitating better detection and response to patient deterioration in the general care unit
Failure to rescue (FTR) is the inability to prevent death after the development of a complication in the inpatient setting, a leading driver of inpatient mortality. According to a 2016 study by researchers at Johns Hopkins, medical errors are now the third leading cause of death in the country. Failure to rescue, specifically, is the third leading cause of death in hospitals.
Our goal was to design a system that facilitates better detection and response to patient deterioration in the General Care Unit at Dartmouth-Hitchcock Medical Center.
Our final solution was a command and control center, a monitoring system designed to prioritize patients based on an algorithm-generated acuity score. It utilized the role of a dispatcher to provide Life Safety Nurses and House Supervisors with the information they need to proactively and efficiently address patient deterioration, with the ultimate goal of minimizing preventable patient deaths.
We designed 3 main views of the command and control user interface: a whole GCU list, a temporal multi-view of patient state, and a dynamic LSN consult list.
In addition to our interface designs, we mapped out an architecture of data inputs and outputs for the system and created a flow chart of how the command and control would be integrated into the daily hospital workflow.
We began our approach by researching medical journals, state of the art, and key terms related to deaths by complication in the hospital that the director of the PSLL provided us with. In addition to our secondary research, we conducted over 25 user interviews on-site at DHMC with a range of healthcare providers, such as members of the PSLL team, resident physicians, registered nurses, life safety nurses, respiratory therapists, and the Chief Quality and Value Officer of DHMC. We also interviewed individuals outside of DHMC who worked in areas related to patient safety, including a former Epic Systems engineer and the founder of Mothers Against Medical Error.
In order to organize the data we collected and find trends, we used a variety of synthesis methods:
Detailed patient care journey map identifying pain points and bright spots of hospital procedures and dynamics.
User personas to empathize with and understand the needs of key people of interest.
Ecosystem diagram to show how these people and other hospital resources relate to one another.
Perceptual map to show which hospital staff interact with patients the most.
All of these methods helped us to extract 3 major insights which we would later use to guide our ideation and prototyping:
Learning hospitals are inherently hierarchical in terms of experience and power, which affects detecting and addressing patient deterioration, respectively.
Healthcare providers need both quantitative and qualitative data to holistically understand a patient’s state, but getting the necessary combination of both requires time and effort for all providers, often through systematically inefficient means.
Individual workflow practices and lack of standardization for cross-departmental handoffs create discontinuities within the whole GCU system and prevent the team from getting on the same page about a patient, causing delayed or lost information.
Based on our research and insights, we brainstormed numerous ideas that addressed the pain points we identified through our synthesis methods.
We narrowed down our potential ideas to the most promising solutions and sketched out the key features of the user interface as well as detailed how it would be used in the hospital system.
We then created a more fleshed out version of our main idea, the command and control center. Our first prototype was a clickable demo made in Figma, an interface design tool.
We shared our prototypes with the PSLL team and other hospital staff, who gave us feedback on what they liked, areas of improvement, and other directions to explore.
Following our meetings with hospital staff, we synthesized the feedback we received, determined which areas to further develop for our next iterations, then repeated the design process.
Special thanks to my teammates (front row, left to right), Emma, Paula, and Monica.