DOCPASS
Assessment of the readiness for work in
surgeons and anaesthetists before an
OR surgery to improve and ensure
safety of surgical patients.
B.M. de Niet
August 2016
Master Thesis Medical Informatics
University of Amsterdam
Supervisors:
Prof. J.K. Sluiter, MBA
Prof. M.H.W. Frings-Dresen
Dr A.C.J. Ravelli
Development, usefulness and feasibility in
surgical practice.
DOCpass: assessment of the readiness for work in surgeons and anaesthetists
before an OR surgery to improve and ensure safety of surgical patients.
Development, usefulness, and feasibility in surgical practice.
Student
B.M. de Niet, BSc.
Student number: 10158049 E-mail: b.m.deniet@amc.uva.nl
Mentors
Prof. J.K. Sluiter, MBA
Director Amsterdam Public Health Research Institute, Principal Investigator Coronel Institute of Occupational Health, AMC
E-mail: j.sluiter@amc.nl Prof. M.H.W. Frings-Dresen
Director of Coronel Institute of Occupational Health, Principal Investigator Coronel Institute of Occupational Health, AMC
E-mail: m.frings@amc.nl
Tutor
Dr A.C.J. Ravelli
Scientific staff member (UD) Department of Medical Informatics E-mail: a.c.ravelli@amc.uva.nl
Scientific Research Project location
Coronel Institute of Occupational Health Department of Medical Informatics Academic Medical Center
Meibergdreef 9 1105 AZ, Amsterdam
Scientific Research Project period
CONTENTS
Abstract ... 3
Samenvatting ... 4
1. General introduction ... 5
1.1 Background ... 5
1.2 Fitness for Work ... 5
1.3 Existing Instruments ... 6
1.3.1 Workers’ Health Surveillance ... 6
1.3.2 SURPASS checklist ... 6
1.3.3 I’M SAFE checklist ... 7
1.3.4 Fit to Perform self-test ... 7
1.3.5 Weaknesses existing instruments ... 7
1.4 DOCpass ... 8
1.4.1 Individual characteristics and patient safety ... 8
1.4.2 Instrument Description ... 8
1.4.3 DOCpass in practice ... 9
1.4.4 Requirements and Aims ... 9
1.5 Outline Thesis ... 10
1.5.1 Objectives ... 10
1.5.2 Research Questions ... 10
1.5.3 Chapters ... 10
2. Surgeon and anaesthetist health aspects related to physician performance and patient safety . 11 2.1 Methods literature review ... 11
2.1.1 Search Strategy ... 11
2.1.2 Inclusion Criteria ... 11
2.1.3 Article Selection ... 12
2.1.4 Data Extraction ... 12
2.2 Results literature review ... 12
2.2.1 Selected Articles ... 12
2.2.2 Health Problems ... 14
2.2.3 Effects of Health Problems on Physician Performance ... 15
2.2.4 Assessment Methods ... 15
3. Development and design of DOCpass ... 17
3.1 Content creation DOCpass ... 17
3.1.1 Screening questions ... 17
3.1.2 Threshold values ... 19
3.1.3 Feedback ... 19
3.2 Design and development DOCpass ... 26
3.2.1 Platform ... 26
3.2.2 Design DOCpass ... 30
4. Usefulness and feasibility of DOCpass in surgical practice ... 31
4.2 Procedures ... 31
4.3 Questionnaire and interview questions ... 32
4.4 Results usefulness and feasibility study... 32
4.4.1 Usefulness DOCpass ... 32
4.4.2 Feasibility DOCpass ... 33
5. General Discussion and Conclusion ... 36
5.1 Main Findings ... 36
1. What health aspects in relation to physician performance and patient safety should be included into DOCpass? ... 36
2. How can DOCpass be designed best based on the pre-defined requirements? ... 36
3. What is the usefulness and feasibility of the DOCpass prototype in practice? ... 37
5.2 Strengths and Points of Improvement of Approach ... 37
5.2.1 Strengths... 37
5.2.2 Points of Improvement ... 38
5.3 Implications ... 39
5.3.1 Improved awareness of influences on performance among surgeons and anaesthetists ... 39
5.3.2 Improved quality of care and patient safety ... 39
5.3.3 Possible change of physician attitude and working culture in surgery ... 39
5.3.4 More attention to surgeon and anaesthetist health on organizational level ... 40
5.4 Recommendations and future research ... 40
5.4.1 Future Research ... 40
5.4.2 Recommendations ... 41
5.5 Conclusion ... 41
References ... 42
List of abbreviations ... 48
Appendix A: Literature review ... 49
Appendix B: Platform choice DOCpass ... 59
Appendix C: Design and development DOCpass ... 61
ABSTRACT
Background: Safety in surgical patients can be endangered by the imbalance between work demands and
worker health status of the treating surgeon or anaesthetist. Accidental patient damage and adverse events due to committed errors are common in surgical specialties and a reduced physical and mental health, but also high physical job demands might be of influence on the quality of delivered care. It can therefore also endanger patient safety. In current practice, work readiness is not yet checked before the start of a surgery operation. For this reason, it is important to develop an instrument to help surgeons and anaesthetists to signal a less than optimal health state and remind them that this state could be of influence on their performance to prevent them from committing unnecessary errors during work.
Research questions and aims: This thesis aims to (1) develop the DOCpass instrument to give physicians
the option to regularly check their work-related health status and work readiness (am I capable to work at this moment and is there a chance that my performance will be impaired?) during a shift. Beside this, also (2) usefulness and feasibility of the developed instrument in practice will be studied. The research
question that will be answered is: How can the use of web-based technology help surgeons and anaesthetists to monitor their own readiness for work status before an operation and what is the usefulness and feasibility of this instrument in practice?
Methods: DOCpass was developed in two phases; content creation and instrument design and
development. To determine the content, a systematic literature review was conducted in PubMed to identify concepts related to surgeon and anaesthetist health that can influence performance and patient safety. Based on the results of phase 1 and a set of pre-defined requirements (the instrument should be easily available, give short and helpful advices, assess readiness for work, take not more than three minutes to be filled in), a prototype was developed in HTML and JavaScript in a (mobile) website format. Threshold values were set based on found literature in order to determine from what point on a health state could be of danger for patient and physician safety. With this, feedback and practical tips were written to improve alertness and work readiness. Usefulness and feasibility was eventually studied in a sample of end users (n = 5) in surgical practice.
Results: DOCpass screens for aspects of fatigue or sleepiness and mood states. Fatigue is screened with
five questions and/or methods and for mood states six items were included. The DOCpass prototype is eventually developed as (mobile) internet website. This way it is easily available for surgeons and anaesthetists on their personal devices and OR computers before every operation and during shifts. Five surgery and anesthesiology residents and seniors have tested the instrument in daily practice. Online web questionnaires and one more in depth questionnaire were collected to study the usefulness and feasibility of DOCpass in surgical practice. Four out of five people believed that DOCpass could possibly help them to become more self-aware of personal limitations and capabilities to perform optimally at work. Three out of five people in the end also believe that the instrument could be capable of helping to decrease the chances of committing errors in surgical practice.
Conclusion: The DOCpass instrument to assess readiness for work has potential, as found in the end user
population, to help surgeons and anaesthetists to become more self-aware of their personal limitations to perform at their best during a shift. The majority of the small participant group also believe that the instrument could be capable of helping to decrease the chances of committing errors in the operating room. The concept of DOCpass is good but the content needs a revision to be successful in actual practice.
SAMENVATTING
Achtergrond: Patiëntveiligheid in de operatiekamer kan worden bedreigd door disbalans tussen
werkeisen en de gezondheid of huidige staat van welzijn van een behandelend chirurg en/of anesthesist. Vermijdbare en accidentele schade, en adverse events als gevolg van gemaakte fouten in de praktijk komen relatief vaak voor bij chirurgische ingrepen. Een verminderde lichamelijke en geestelijke
gezondheid, maar ook de fysieke werkeisen zoals bijvoorbeeld tijdstip op de dag, kunnen van invloed zijn op de kwaliteit van zorg die wordt geleverd. De vraag is hoe patiëntveiligheid mogelijk kan worden beïnvloed via deze aspecten. Op dit moment wordt de work readiness van artsen nog niet gecheckt voor de start van een operatie. Om deze reden is het daarom ook belangrijk om een instrument te ontwikkelen wat chirurgen en anesthesisten kan helpen om een verminderde gezondheid op tijd te signaleren en hen eraan te herinneren dat deze staat van invloed kan zijn op de kwaliteit van zorg die zij leveren. Dit voorkomt dan hopelijk het maken van onnodige fouten tijdens het werk.
Onderzoeksvragen en doel: Het doel van deze thesis is om (1) een DOCpass instrument te ontwikkelen
om artsen de mogelijkheid te geven om regelmatig en gemakkelijk hun werk-gerelateerde gezondheid en geschiktheid te controleren (ben ik in staat om op dit moment te werken en is er een kans dat mijn prestaties worden geschaad?) tijdens een dienst. Daarnaast wordt (2) ook het nut en de haalbaarheid in de praktijk bestudeerd. De onderzoeksvraag die zal worden beantwoord is: Hoe kan het gebruik van op web gebaseerde technologie chirurgen en anesthesisten helpen om hun werk optimaal uit te kunnen voeren tijdens een operatie en wat is de usefulness en feasibility van dit instrument in de praktijk?
Methode: DOCpass is in twee fases ontwikkeld; opzet van de inhoud, en design van het instrument. Om
de inhoud te bepalen is er een systematisch literatuuronderzoek uitgevoerd in PubMed om concepten te identificeren die betrekking hebben tot de gezondheid van de chirurg en anesthesist die van invloed kunnen zijn op hun prestaties en de patiëntveiligheid. Op basis van de verkregen resultaten in fase 1 en een vooraf gedefinieerde set van eisen (het instrument moet readiness for work beoordelen, gemakkelijk beschikbaar zijn, korte en nuttige adviezen geven, en niet meer dan drie minuten in beslag nemen om in te vullen), is een prototype ontwikkeld in HTML en Javascript in een (mobiele) website omgeving. Drempelwaarden gevonden in de literatuur zijn gebruikt om te bepalen vanaf welk punt gezondheid een gevaar kan zijn voor de veiligheid van patiënt en arts. Op basis hiervan is feedback geschreven met praktische tips om de alertheid en work readiness te verbeteren. De usefulness en feasibility van het instrument is getest in een steekproef van eindgebruikers (n = 5) in de dagelijkse praktijk.
Resultaten: DOCpass screent op aspecten van vermoeidheid of slaperigheid, en gemoedstoestanden.
Vermoeidheid wordt met vijf vragen gescreend en voor de stemming zijn zes items opgenomen. Het DOCpass prototype is ontwikkeld als (mobiele) internetwebsite. Het instrument is hierdoor gemakkelijk beschikbaar voor artsen op hun persoonlijke apparatuur of AMC-computer voor elke operatie en tijdens de dienst. Vijf AIOS-chirurgie en -anesthesiologie, en medisch specialisten hebben het instrument getest in de chirurgische praktijk. De antwoorden op online vragenlijsten en een vijftal diepgaandere vragen zijn verzameld om het nut en de haalbaarheid van DOCpass in de praktijk te bestuderen. Vier van de vijf participanten geloofd erin dat DOCpass er mogelijk voor kan zorgen dat zij zichzelf meer bewust raken van hun persoonlijke capaciteiten om optimaal te presenteren op het werk. Drie van de vijf denkt daarnaast dat het instrument ook kan helpen om de kans op het maken van fouten in de praktijk te verminderen.
Conclusie: De pilotstudie toont dat DOCpass de potentie heeft om chirurgen en anesthesisten te helpen
zelfbewuster te raken van hun persoonlijke capaciteiten om optimaal te presteren. De meerderheid is van mening dat de kans op het maken van fouten in de praktijk kan dalen door inzet van dit instrument. Het DOCpass concept is goed maar de inhoud moet nader geëvalueerd worden om succesvol te zijn in de
1.
General Introduction
1.1 BACKGROUND
The well-known report ‘To Err Is Human’ from the Institute of Medicine (1999) stated that preventable adverse events are a leading cause of death in the United States. These errors can have a human origin and could be prevented by designing a work environment that can ensure patients to be safe from accidental injury. Patient safety is a critical component of quality of care and therefore also subject of many articles and reports in medical literature [1].
From one perspective, patient safety can be endangered by the imbalance between work demands and worker health status of the treating physician. The high and diverse work demands of hospital physicians can affect health status and can impair work performance or functioning, which could induce human errors, adverse events or can even lead to detrimental effects [2].
In this thesis, the focus is on surgeons and anaesthetists in the setting of the operating room within a university medical centre. It’s assumed that these physicians, whether being an experienced doctor or resident, are appointed to be qualified by the organisation to perform their job within the hospital. The impact of human errors in surgical patients can considered to be quite huge because in most cases of care delivery in operating rooms, human lives can be at stake. Also, the more invasive a treatment, the higher the risk is that something can go wrong. It is found that a lot of (near) misses, accidental patient damage and adverse events in hospitals is associated with surgical specialties and providers [3,4]. In the current literature, different studies show that surgeons’ and anaesthetists’ reduced physical and mental health but also high (physical) job demands like for example working in fixed postures and performing repetitive movements [5], long working hours that require high levels of concentration, and production pressure [10] might influence the quality of delivered care. Beside this, patient safety might be endangered. The exposure to several physical job demands that are perceived as uncomfortable and exhausting, and the presence of physical health complaints are said to reduce a surgeons’ work
functioning and performance [5] and are of influence on for example the development of depression in anaesthetists [10]. A Chinese study among anaesthetists found that more than half of the studied
population showed depressive symptoms [11]. Also observations were done that surgeon’s distress or the degree of burnout complaints or mental quality of life in surgeons are related to perceived medical errors [6]. Stress in surgeons is said so to have an effect on impaired judgment, decision making and
communication [7]. Fatigue and sleepiness have beside these as well shown to affect a physicians’ performance [8]. In a recent article the prevalence rates for a couple of common mental disorders were studied among Dutch hospital physicians. These show that the prevalence of work-related fatigue was about 42%, 29% for depression, 15% of the studied population had stress complaints and 6% suffered from high burnout complaints [9]. Mental health problems could not only have negative effects on direct patient care but could also lead to physical problems [11].
Consequences of health problems as previously described are known to be quite prevalent in both medical students, medical residents, and hospital physicians in health care and surgery and can affect a physicians’ performance [5,6,9]. This can increase the risk of endangered patient safety and that could be the difference between life and death when mistakes are made in the operating room [7,8,12].
1.2 FITNESS FOR WORK
during work. In this thesis, the focus will be on fitness for work of surgeons and anaesthetists in this context. Fitness for work although is a broad concept, and therefore the term readiness for work will be used from now on to indicate that the focus is on being ready (enough) to perform your next task. It should be investigated how a surgeon or anaesthetist can check their work readiness on a regular basis to help give correct feedback which can be used to assess whether someone’s health state is a risk for not only patient safety but also the physician’s individual health on the longer term. When performance is impaired, mistakes can have far-reaching negative effects for different groups of people [13].
In current practice at the start of a job, work readiness is not checked for in the form of for example a medical examination. It is therefore the case to help signal a less than optimal health state among surgeons and anaesthetists in terms of their readiness to work and remind them of the fact that his state could be of influence on their performance.
In the literature, there is a couple of different definitions for the “readiness for work” terms as used in the context of this thesis. In this case readiness for work can best be defined as having the mental and
physical capabilities to successfully perform a task and work at present moment without increased risk to their own or others’ health and safety. Being unfit or less than optimal fit then matches with a reduction of mental or physical capabilities due to for example fatigue, depression, (mental or physical) illness, alcoholism or stress [14,15]. This does also include any other aspect that could have an influence on capabilities or work.
An unfit surgeon or anaesthetist can impact different people within an organisation as a hospital. In this thesis, the focus will only be on the stakeholder group of unfit treating physicians that can harm patients and could leave supervisors or managers with possible sick leave and higher rates of incidents or near misses.
1.3 EXISTING INSTRUMENTS
In the Dutch university medical centers, but also outside the domain of medicine, different projects and instruments were already developed in the past that encounter aspects of the described problem in a preventive setting. Below, a list of these already existing instruments are discussed in more detail.
1.3.1 WORKERS’ HEALTH SURVEILLANCE
The Workers’ Health Surveillance (WHS) is an instrument that periodically checks health requirements for a specific job. Currently, one developed for hospital physicians is found feasible and acceptable for early detection of work-related health complaints among hospital physicians. This surveillance is focused on the improvement of health and hereby safety of physician and patient. The WHS consists of screening
questions, a physical examination and a consult with an occupational physician and the main goal of this periodic preventive examination is to detect and prevent work-related health complaints in hospital physicians. The assessment although is not more often performed than once every 2-4 years, which is a large time-lag for use to monitor and improve patient safety on the short term [22].
1.3.2 SURPASS CHECKLIST
When further looking at medicine, one of the projects on the subject of patient safety was the
development of the SURPASS (SURgical PAtient Safety System) checklist as used by surgery teams in every patient before he or she is treated in the operating room. With the implementation of the SURPASS checklist, it was aimed for that it would help reduce surgical complications and mortality, and therefore improve patient safety, by standardizing processes along the surgical pathway from admission to discharge of a patient. It’s a multidisciplinary checklist in which surgeon, anaesthetist, and assistants are
recovery room) and each step also includes a mandatory time out to reflect on whether all checks at this point of the surgical pathway have been done and authorised. The checks include subjects as
administered pre-operative medication and presence of medical equipment. Only when all checks have been done and authorised, the process can be continued. This automatically means that when a patient is in actual surgery, all steps have been checked and authorized. Patient safety is the main focus in this checklist and goal is to prevent avoidable mistakes. The checklist is currently used in almost every Dutch hospital whether using the actual SURPASS or a local adoption of the checklist; in all cases the Dutch guidelines are followed. It is not yet well monitored whether it is used in every single surgical patient. In a multicentre study, the implementation of the SURPASS checklist was associated with a reduction in postoperative complications and in-hospital mortality within the intervention hospitals; the postoperative complication rate decreased from 27.3 per 100 patients before implementation to 16.7 per 100
afterwards and the in-hospital mortality reduced from 1.5 to 0.8% [19,20,21].
1.3.3 I’M SAFE CHECKLIST
An important example of an instrument that suggests to do what DOCpass is aiming for is the “I’M SAFE checklist” as used in aviation pilots. This checklist was developed to self-assess their physical and mental state before a flight to create awareness about personal limitations. It’s a pre-flight checklist that is used
throughout a professionals’ career before any flight to assess overall readiness to fly. It serves as an alert to pilots that it could be possible that he or she is not likely to perform at its best. It summarizes the most important factors that could affect a pilot’s ability to perform well and consists of questions on illness, medication, stress, alcohol, fatigue, emotion or eating (see figure 1). When a question is answered in the affirmative, it does not immediately mean that the pilot in case is unfit to fly, but it does indicate that performance is likely to be
impaired. Outcomes of the checklist are only visible for the respective pilot. When a pilot is aware of this likelihood, procedures could be put in place and the decision to fly can be re-evaluated by the pilot in question to help prevent and minimize harmful errors and effects in practice [16,17,18].
1.3.4 FIT TO PERFORM SELF-TEST
An instrument that aims to measure both objective alertness and subjective sensations of fatigue among medical professionals was already developed and tested in a pilot for the Fit to Perform study that has started their tests in clinical practice in 2015. Within this project they make use of a ‘Fit to Perform self-test’ that measures alertness, concentration, hand-eye coordination, and fatigue in three blocks that take a total of eight minutes; at a moment of optimal fitness, measurements and data that can be compared to a frame of reference. The obtained data from the measurements will hopefully create more awareness on this subject and can eventually be used for the optimization of patient safety, to customize work hour limitations, and increase the quality of life of medical professionals [23,24].
1.3.5 WEAKNESSES EXISTING INSTRUMENTS
As stated, there are already quiet some instruments available to use as prevention to ensure safety in Figure 1: I’M SAFE-checklist
either a healthcare or non-healthcare environment. To be able to effectively implement it in surgical practice that we are currently aiming at, the following aspects are missing:
The instrument should give the possibility to check health status or aspects of health more
frequently throughout the day or night because it is a fluctuating state rather than a state that can be checked for every couple of years.
The instrument should give the possibility to check yourself on aspects of health instead of being checked on it and needing help during the check.
This check-up you perform should not take much of your time.
There is therefore also a need for an instrument that focuses on the healthcare professional and the entire operating room environment (which is including both surgeons and anaesthetists) rather than just the patient.
There is also no such instrument yet that takes personal assessment of health and health aspects into account.
1.4 DOCPASS
The Coronel Institute of Occupational Health (AMC, Amsterdam) in The Netherlands suggests that a solution for surgeons and anaesthetists should be found that combines elements from previous described instruments to give physicians the option to regularly check their work-related health status and work readiness or fitness several times throughout a shift; am I capable to work at this moment or is there a chance that my performance will be impaired?
1.4.1 INDIVIDUAL CHARACTERISTICS AND PATIENT SAFETY
The delivery of care is based on the assumption that surgeons and anaesthetists are aware of their own capabilities and limitations at moment of action. Self-awareness is a personal characteristic that is found to be essential for surgeons and anaesthetists, but also medical specialists in more general, by the Accreditation Council for Graduate Medical Education [27]. It is in cases although known that especially medical specialists find it at times difficult or are not comfortable admitting that they are ill because of the culture and environment they are trained and work in. Their attitude towards being ill and becoming doctor-patient may be of influence when self-assessing their readiness [15,25,26]. Humans in general also tend to be unrealistically optimistic about their health; they perceive themselves to be at lesser risk for negative health outcomes than a peer and could therefore also not want to admit when they actually are ill or when their health is affected [29]. Research also has shown that inaccurate self-assessment of surgeons is a risk to getting overconfident or unconsciously incompetent doctors, which has shown to jeopardize patient safety [30].
Creating self-awareness among healthcare professionals could be one aspect of error prevention to guarantee patient safety. This patient safety is a critical component of quality of care [1] that physicians find really important. In a report from the World Health Organization (WHO) it is stated that there are also many different factors at the individual level of a physician that could be of influence on safety outcomes in practice. One of these factors is ‘being aware of your situation’, but with this also being aware of how your own personal health state could result in medical errors and how you can personally resolve this [31].
1.4.2 INSTRUMENT DESCRIPTION
It’s the aim to develop an instrument that gives surgeons and anaesthetists the option to regularly check their work-related health status and work readiness or fitness at the start of their shift or operation. This for the early identification of possible health problems that could be of impact on physician performance and safety outcomes. Information that will become available and advices that are given after the
physician has performed the check will hopefully create awareness among these health professionals about their current health state or work readiness. This awareness and the practical tips that are provided can then be used in practice to help prevent them from committing unnecessary errors during work which
health state, especially with colleagues.
1.4.3 DOCPASS IN PRACTICE
Below in figure 2, a scheme can be found that graphically illustrates the eventual use of DOCpass in practice. On the one hand, there are the surgeons and anaesthetists. These are either experienced doctors or residents but they are in all cases found to be qualified to perform their job by the organisation of a certain medical center. On the other hand, is the system of the department and/or organisation each physician works within. This includes having a particular workload and working schedules, and performing their certain tasks. DOCpass will be used as checklist in between the physician and the work they perform to check a couple of important factors that could influence a surgeons’ and anaesthetists’ health state and performance. Factors that will be evaluated could include stress, fatigue, alcohol and medication usage but also aspects related to work will be taken into account as for example the time since when someone was awake, the time since the last period of having at least five hours of sleep, and the number and duration of OR surgeries in the last 24 hours. When the instrument is taken into use, this will have a certain effect or impact in practice and on a physicians’ actions and behaviour. This impact will eventually either have a positive or negative effect on patient safety. The future end goal is to be able to positively influence safety of surgical patients by using DOCpass in surgical practice.
1.4.4 REQUIREMENTS AND AIMS
As introduced by the Coronel Institute of Occupational health, DOCpass has to
assess a surgeons’ and anaesthetist fitness for work based on aspects related to personal health in relation to work.
give short and helpful personal advices (as will fit into the working culture) about current fitness to work state based on scientific literature given the filled in answers.
be one instrument that takes not more than two to three minutes to be filled in after which
personal advisory feedback can be given on the different aspects of personal health and work based on threshold values as found in literature.
be easily available for surgeons and anaesthetists to use before every shift or operation. be comprehensible for the surgeon or anaesthetist.
With the DOCpass system we aim for the following:
It should give surgeons and anaesthetists the option to easily and regularly check their work-related health status and work readiness or fitness to become more self-aware of their possible personal limitations in performance and their capacity and ability to perform optimally at work;
It should serve as an educational tool that gives short and helpful personal univariate advices and feedback to users;
Eventually, using this instrument should indirectly positively influence, and improve and ensure patient safety in practice.
1.5 OUTLINE THESIS
1.5.1 OBJECTIVES
To give physicians the option to regularly check their work-related health status and work readiness or fitness (am I capable to work at this moment and is there a chance that my performance will be impaired?), the DOCpass system will be introduced.
The objectives for this thesis are in the first place to develop a prototype assessment instrument for a surgeons’ and anaesthetists work readiness (DOCpass system), and second to study usefulness and feasibility of the instrument in practice in one university medical center.
The validity testing of the DOCpass tool will not be in the scope of this scientific research project. This is the case because of the lack of a golden standard it can be tested against. Further research has to be done at first on how validity of work readiness requirements can be tested.
1.5.2 RESEARCH QUESTIONS
The research question in this thesis is:
How can the use of web-based technology help surgeons and anaesthetists to monitor their own
readiness for work status before an operation and what is the usefulness and feasibility of this instrument in practice?
The sub questions that were selected are:
1. What health aspects in relation to physician performance and patient safety should be included into DOCpass?
2. How can DOCpass be designed and developed best based on the pre-defined requirements? 3. What is the feasibility and usefulness of the DOCpass prototype in practice?
1.5.3 CHAPTERS
The next chapters of this thesis focus on three related subprojects that were performed in the time span of eight months as part of the Medical Informatics Scientific Research Project (SRP). Each subproject focuses on a component or aspect of the development process of the DOCpass system.
First, the content of DOCpass had to be determined by performing a restricted systematic literature review. Methods and results of this review can be found in the next chapter.
With the results of the literature review, DOCpass could be developed. The third chapter will therefore be about the development and design of DOCpass. Chapter 4 will then discuss its usefulness and feasibility in surgical practice.
Finally, chapter five presents an overall conclusion and discussion of this thesis. This part also includes recommendations for future research.
2.
Surgeon and anaesthetist health aspects related to physician
performance and patient safety.
2.1 METHODS LITERATURE REVIEW
A restricted systematic literature review was conducted to determine what health aspects in relation to physician performance and patient safety should be included into DOCpass. To determine these aspects, important health problems in surgeons and anaesthetists that could induce human errors and affect performance were searched for in literature.
The following research questions are addressed:
A. What important health problems in surgeons and anaesthetists are known in literature that could induce human errors?
B. What impact do the earlier found health problems have on physician performance in practice? C. How can these health problems that have a negative effect on physician performance best be measured or screened within surgeons and anaesthetists?
2.1.1 SEARCH STRATEGY
The PubMed search engine was used to access the Medline database which covers a broad part of the biomedicine and health scope. Size and completeness of the database was a major reason for this choice. This database was searched for articles in English using a search strategy that combined three groups of search terms into systematic queries. This was done using both free text keywords and Medical Subject Heading (MeSH) terms depending on the research question to be answered. We were looking into articles that specifically studied the relationship between a primary health problem and the possible induction of (human) errors and/or influence on physician performance.
For the first two questions (A and B), group #1 concerned terms associated with surgeons, anaesthetist or residents from either specialty. Group #2 included terms on health problems, which if necessary could be subdivided into terms on health problems in more general (group #2A), and terms on more specific health problems as were found during the search in the orientation phase of the project (group #2B). Group #3 finally included terms on either human errors or physician performance. An overview of the keywords is given in table 2.1 and 2.2 as can be found in appendix A. Terms in each group were combined by using the “OR” operator, while the different groups of terms were combined by “AND”. Extended search queries can be found in appendix A.
The third question (C) is of a different kind and was posed to find methods to measure the found health problems in surgeons that have a negative effect on physician performance. These methods could be used to design the content of the DOCpass system. All articles that were at first found relevant for questions A and B after application of inclusion criteria were scanned again for their method as used to identify and determine the studied health problem.
After combining the different categories of terms, filters and restrictions were set to get a group of possible relevant results that were limited to the past ten years starting in 2005 until February 2016 and written in English. This selection is assumed to contain the most actual health problems related to human errors and physician performance as were found in surgeons and anaesthetists The search fields that were searched in are title and abstract.
Results as found in research question A were used as input in question B. Research question C was answered using both the results of question A and B.
2.1.2 INCLUSION CRITERIA
For this literature review, a couple of inclusion criteria were maintained and only applied on title and abstract:
2) articles had to be no older than 2005 to get the most relevant and representative health problems related to human errors as were found in these groups of physicians;
3) articles had to study found health problems and issues that occur in the defined groups of physicians; 4) articles had to study an association between the health problem and the possibility of it inducing human errors or have to support the assumption made that the studied health problem could induce human errors;
5) articles had to be written in English;
6) and only primary research articles would be included.
2.1.3 ARTICLE SELECTION
All found articles were firstly reviewed and selected based on title and abstract. If the title was found relevant and in compliance with inclusion criteria, abstracts were read. If still found relevant, articles were included in advance. For this selection, full text was retrieved and analysed. At this level, only articles that could answer the research question and were in compliance with the inclusion criteria were eventually selected. Everything was done by one person.
2.1.4 DATA EXTRACTION
A data extraction table was generated to summarise important aspects of the full text retrieved articles. This table included variables on study population and country, and study design but also summarised the health problem and the type of (human) errors and impact on performance that was studied and the measures that were used to identify and determine the health problem and results of the performed study. Based on the results, an either significant hypothesized, significant not hypothesized adverse or no association or effect was identified. The found associations were between health problems and the induction of human errors or health problems and the impact this has on physician performance. In each table, the dependent and independent variables were indicated. Data was abstracted by one person. When in doubt about inclusion, there was a meeting organised with the project group to reach consensus on inclusion of articles.
2.2 RESULTS LITERATURE REVIEW
In the following sections, the results of the literature review will be presented. Discussion and conclusions on these results can be found in the general discussion in chapter 5.
2.2.1 SELECTED ARTICLES
For the literature review, three questions had to be answered; (A) What important health problems in surgeons and anaesthetists are known in literature that could induce human errors?, (B) What impact do these health problems have on physician performance in practice?, and (C) How can these health problems that have a negative effect on physician performance best be measured within surgeons and anaesthetists?. Results for these question were all worked out separately in their own data abstraction table which can be found in appendix A.
The overall search yielded a total of 976 references (A: 421; B: 555). All found references were reviewed for title and abstract and a selected amount was reviewed in full text. This was done by one person and resulted in a final inclusion of 6 articles for question A, and 7 for question B. This selection includes eight unique references (Gerdes, Kahol, de Oliveira, Klein, Shanafelt, Schwenk, Kang, Ruitenburg
[32,33,34,35,36,37,38,39]). Figure 3 and 4 show the more detailed flows of the article selection process for both research questions. Reference lists were if found useful checked for other possible relevant studies. Also sources as found in the first phase of the project to obtain background information on the subject have been included.
In all studies, data was primarily obtained through either a questionnaire or survey, and either surgeons, surgical clinicians or residents were studied in the different samples. For more details on study
characteristics see appendix A.
The assessment methods for health problems in research question C were selected based on the results as found in question A and B. In order to expand the search field, it was chosen to review more articles than were eventually included for question A and B (A: 6; B: 7). The total amount of 105 articles that were reviewed in full text for these questions, were therefore afterwards also reviewed for methods and materials used. After review, 94 were not found relevant because the methods used were either too long to include into our tool or the health problem studied within the article was already excluded from our search. A total of 11 articles with possible relevant assessment methods remained.
The assessment methods found included both validated and non-validated methods. The types of instruments as used in the studies varied from single to multiple questions, (validated) scales, and (parts of) (validated) questionnaires.
2.2.2 HEALTH PROBLEMS
Research question A investigated in what important health problems in surgeons and anaesthetists are known in literature that could induce human errors. The included articles studied three different health problems: fatigue (n=2 [32,33]), burnout (n=3 [34,35,36]) and depression (n=3 [34,36,37]). Fatigue was in this review limited to suffering from the primary health problem that is fatigue. Working night shifts, performing post night-time procedures, the time when care was provided, and other exposure or proxy measures were not included into the search. Also for burnout and depression applied that the primary health problem and/or symptoms had to be studied.
Some studies investigated multiple health problems alongside each other. These outcomes were all significantly associated with an either increase in committed (cognitive) errors or decrease in physician performance in some way. It’s assumed that these results are of influence on physician performance and should be considered to be of interest to evaluate by using DOCpass. For details on included studies see Appendix A.
2.2.3 EFFECTS OF HEALTH PROBLEMS ON PHYSICIAN PERFORMANCE
Research question B investigated the impact of the earlier found health problems fatigue, burnout, and depression on physician performance in practice. All articles studied an association between a health problem and the induction of (human) errors; here it was assumed that the health problem is of negative effect on physician performance (Gerdes, Kahol, Kang, Ruitenburg, de Oliveira, Klein, Shanafelt,
Ruitenburg [32,33,34,35,36,38,39]). In all included articles, a significant hypothesized association was found for this assumption. This means that all associations were significantly found to be in favour of the health problem possibly endangering patient safety, as was assumed at the start of the literature search.
Fatigue was found to be associated with an increase in numbers of cognitive errors made during a night call [32]. While on a night call, Gerdes et al showed that 32% more errors were made than during a day call. This study showed that the more fatigued a surgeon is, the higher the risk is of causing cognitive errors. Also Kahol et al have in their study showed that fatigue is significantly associated with a decrease in cognitive skills (p < .01) and therefore increase in number of cognitive errors made [33]. Kang et al confirmed these findings with the results of their own univariate logistic regression which shows an association of having a 37% higher chance of perceiving a medical error when fatigued (OR: 1.37; 95% CI [1.12-1.69]; p < 0.003) [38]. Also the study done by Ruitenburg et al shows that fatigued physicians are 3.5-fold more likely to report insufficient work ability [39].
Burnout was as well found to be associated with either a higher report and increase of committing medical errors. De Oliveira et al found that 33% of their studied population that have high burnout and depression risk, have reported to have made medical errors in comparison to 0.7% of the studied population with low risk (p < 0.001) [34]. Also Kang et al found associations between emotional exhaustion and depersonalization, and perceived medical errors in physicians. Per unit increase of emotional exhaustion or depersonalization, perceived medical errors increase as well with an odds ratio of either 1.07 for emotional exhaustion (95% CI [1.02-1.13]; p < 0.005) and 1.11 for depersonalization (95% CI [1.02-1.21]; p < 0.013) [38]. Klein et al also found an association between burnout and suboptimal perceived quality of care, beside an increase of errors made. Burnout was associated with perceiving quality of given care as suboptimal in both male and female surgeons with odds ratios varying between 1.3 and 2.6 for different aspects of quality of care [35]. Shanafelt et al have also been studying the perception of making medical errors. They found that reporting medical errors is associated with having a degree of burnout and symptoms of depression. Each point increase in depersonalization is associated with a 11% increase in likelihood of reporting an error. This is 5% in case of emotional exhaustion. Lapses in judgment and concentration were also found to be contributing factors in recent reported errors by a majority of the participants [36]. Ruitenburg et al lastly, found that physicians with burnout complaints are 9.5-fold more likely to report insufficient work ability which can be of negative influence on performance [39].
Also for depression several associations of the health problem with aspects of physician performance were studied. Kang et al had found an increased risk of committing medical errors when screening positive on a depression test. This study showed that a negative depression screen was associated with perceived medical errors with an odds ratio of 0.29 (95% CI [0.11-0.76]; p < 0.013) [38]. Shanafelt et al also confirm this association with having found that reporting major medical errors is statistically significant associated with having symptoms of depression [36]. Ruitenburg et al in addition also show that physicians with depression are 10.8-fold more likely to report insufficient work ability [39]. All included studies can be found in Appendix A.
2.2.4 ASSESSMENT METHODS
The found articles all used a wide variety of identification or assessment methods to evaluate or identify a specific health problem. For research question C, all (if possible validated) methods that were possibly found relevant for DOCpass were investigated and can be found in table 2.3.
To assess fatigue, nine methods were found that could possibly be used in the DOCpass instrument. The methods include different types of questions to get information on a person’s sleep status (3) [40,41,42],
scales to assess either sleepiness (5), subjective fatigue levels, sleep disturbance, fatigue after work, work-related fatigue, and tiredness [32,39,43,44,45], and questionnaires to assess both physical and mental health (1) [47].
For the assessment of burnout, three different methods were found. All of them use the Maslach Burnout Inventory (MBI) but they differ in the number of items used to assess different aspects of burnout. This varying from using 13 items in total [39], 5 items in total to assess emotional exhaustion [44], or the shorter 2-item assessment that have been shown to correlate with burnout [46].
Two different methods were found to assess depression. Depression could be assessed by using the validated Patient Health Questionnaire depression module (PHQ-9) [37] that has nine items in total or the 2-item Primary Care Evaluation of Mental Disorders screener (PRIME MD) [36].
Table 2.3 Possible relevant methods to use in DOCpass as found in literature review
Health problem # Methods found Methods
Fatigue 9 1. Number of hours slept, number of hours worked.
2. Number of hours into shift, number of surgeries in the last 24.
3. Visual Analogue Scale (VAS) to measure subjective perception of tiredness.
4. The need for recovery after work scale from the Dutch Questionnaire on the Experience and Evaluation of Work. 5. Karolinska Sleep Questionnaire.
6. 3-item scale for fatigue after work.
7. Numerical Rating Scale for Fatigue (NRS-F). 8. Stanford Sleepiness Scale (SSS).
9. 8-item Short Form Health Survey (SF-8).
Burnout 3 1. 13-item Maslach Burnout Inventory (MBI).
2. 5-item Maslach Burnout Inventory (MBI) to assess aspects of emotional exhaustion.
3. 2-item Maslach Burnout Inventory (MBI).
Depression 2 1. Patient Health Questionnaire depression module (PHQ-9). 2. 2-item Primary Care Evaluation of Mental Disorders
3.
Development and design of DOCpass.
In this section, the main focus will be on the actual content of DOCpass and its actual development and design. It will be addressed what health aspects should be included into the instrument and how these aspects should be measured or screened. Attention is also drawn on how and in what way users will be warned about their possible reduced health state and performance, and what advices will then be given out in this case. Beside the content of DOCpass, also the platform development and design will be discussed. Discussion on the results can be found in chapter 5.
DOCpass was designed and developed in two phases:
1. Content creation: content was created by collecting important health problems or work related aspects that occur in surgeons and anaesthetists that could be screened in the instrument. These problems or aspects were found to be of influence on their performance and therefore patient safety.
2. Instrument design and development: based on the results from phase 1 and predefined requirements a platform for DOCpass was selected and a prototype was build.
3.1 CONTENT CREATION DOCPASS
To determine the content of DOCpass, a systematic literature review was conducted in PubMed. In this review, concepts related to surgeon and anaesthetist health were identified that can influence
performance and patient safety. Because two physician groups are studied, separate keywords were used to search for health aspects in literature. In our case we were interested in important health problems or aspects in surgeons and anaesthetists that could induce human errors and affect performance. Beside this we were looking for methods or screening options to measure the found aspects. The methods and result of the literature review were already discussed in more detail in chapter 2 of this thesis.
The literature review resulted in possible health aspects that could be screened for in DOCpass.
Consensus was reached within the project group on final inclusion of aspects and appropriate (validated) screening methods. Also threshold values were set in order to draw a line from what point on a health aspect could be of danger for both physician and patient safety. Background information from literature was used to write advices users will see as feedback when DOCpass is filled in. Each advice consists of an assessment of current health state, background information, and practical tips to improve alertness and work readiness if necessary.
3.1.1 SCREENING QUESTIONS
Scientific literature shows that three health problems or aspects of health are important in surgeons and anaesthetists that could induce human errors. These are fatigue, burnout and depression
[32,33,34,35,36,37]. All aspects are found to be significantly associated with either an increase in committed errors or decrease in physician performance [32,33,34,35,36,38,39].
Based on these findings, it was decided within the project group what aspects are in line with the requirements of the instrument and were eventually included in DOCpass. Health aspects and related screening methods were included when (i) it was found in literature to be of impact on physician performance, (ii) it concerned aspects of health with acute rather than chronic symptoms, and (iii) when screening methods were eligible for screening more than once a day. Screening methods were also checked for validity of the method, but this wasn’t necessarily a requirement for inclusion of the method as long as the question or method could be scientifically supported. Eventual content of DOCpass includes screening on aspects of fatigue or sleepiness and mood states.
Mood states were chosen in favour of burnout and depression because the latter both have chronic complaints which are hard to measure in an acute way. The requirements of DOCpass insist that it should make it easier for surgeons and anaesthetists to check their work readiness on a regular basis. What can be measured regularly are (early) symptoms which can be captured by the assessment of states of mood.
A total of five questions and/or methods were selected for the screening of fatigue. This included four single questions drawn from literature on aspects of sleep and characteristics of duty [32,33,38,39,47], and the validated Stanford Sleepiness Scale that measures alertness [45]. To screen mood states, six items from the validated Profile of Mood States scale were included [48]. Screening questions and rationale for inclusion can be found in table 3.1 and 3.2.
Table 3.2: Mood screening methods used in DOCpass and rationale for usage
Health aspect Screening method Importance
Mood Profile Of Mood States (POMS) [48] De omschrijving past bij mijn gevoel van dit moment:
a. Slecht gehumeurd b. Uitgeput c. Geërgerd d. Knorrig e. Vol energie f. Helder
Instead of screening on symptoms of either burnout and depression (which are chronic symptoms), it’s better to take a step back and look at aspects of mood. Being in a particular mood can also be an early symptom of either burnout or depression, and can in this case be used as indicators for an influenced
performance.
Table 3.1: Fatigue screening methods used in DOCpass and rationale for usage
Health aspect Screening method Importance
Fatigue 1. What time is it at the moment?
It’s found that more errors are committed during night calls when the subjective fatigue rating is higher [32,33]. Also specific time periods in a day can be more tiring for humans.
2. How many full hours have you slept before starting this shift?
When more tired and fatigued, and when your sleep is shortened, you have a higher risk of committing errors and reporting insufficient work-ability. [38,39,47]. 3. How many hours are
you into your current shift?
Based on getting regular breaks throughout the shift.
Being further into a shift has shown to result in higher subjective fatigue levels which is associated with a higher risk to committing more errors and having injuries and accidents [32,33,47].
4. How many hours has it approximately been since your last break?
Rest breaks will lower risk of committing errors during work; the longer the working period is without a break, the higher the risk [47, 53]
5. Stanford Sleepiness Scale
The more fatigued you feel, the higher the risk of committing errors and having a decreased work-ability [32,33,38,39].
3.1.2 THRESHOLD VALUES
For the selected screening questions and methods, threshold values were set in order to determine from what point on a health state could be of danger for both the physician and patient. These values are based on evidence as found in literature. Important for fatigue and sleepiness for example are the times at which it is challenging to stay concentrated due to your circadian rhythm. Adults on the contrary also need a particular time of sleep per 24-hour period to be able to function optimally. These aspects are screened within the instrument. With the set values, distinction is made between having a lower, intermediate or higher extra risk of committing errors and incidents in surgical practice. Full and more elaborated list of content, outcome measure, and threshold values is listed in table 3.3 and 3.4 which can be found in appendix C.
3.1.3 FEEDBACK
The extra risk DOCpass assesses is used in decision rules that are based on the set threshold values to provide users with feedback. This feedback is an advice that includes practical tips to improve alertness and work readiness if the extra risk of committing errors and incidents is either intermediate or high. Extra risk is shown in either the colour orange or red to alert users of their health state. When there is a low risk, users will be provided with positive feedback shown in green. No distinction is made between the two separate user groups of surgeons and anaesthetists; every user is provided with the same feedback.
The advices are based on the answers as given by the users. When an extra intermediate or high risk of committing errors and incidents is assessed, evidence based strategies or tips are provided to
immediately improve alertness and work readiness in surgical practice. These tips and strategies variate from listening to the radio or music, talking with colleagues, and eating healthy snacks or chewing gum to stay awake and more concentrated, to staying active in practice and analysing current (mood) state to improve work readiness at a particular moment in time [49,50,51,52]
Table 3.5: Full feedback as given in DOCpass based on filled in answer
Health aspect Screening method Threshold value(s) or answering options Feedback
Fatigue 1. What time is it at the moment?
22.00-07.00 Het werken nachtdiensten verhoogd het risico op incidenten
of het maken van fouten. Blijf alert door bijvoorbeeld: Voldoende water te drinken
De radio aan te zetten
Met collega’s te blijven praten Of op kauwgom te kauwen.
02.00-04.00 Goed wakker en alert blijven op dit tijdstip kan moeilijk zijn en leid eerder tot incidenten of het maken van fouten. Blijf alert door bijvoorbeeld:
Voldoende water te drinken De radio aan te zetten
Met collega’s te blijven praten Of op kauwgom te kauwen.
13.00-15.00 Goed wakker en alert blijven op dit tijdstip kan moeilijk zijn en leid eerder tot incidenten of het maken van fouten. Blijf alert door bijvoorbeeld:
Voldoende water te drinken De radio aan te zetten Of op kauwgom te kauwen.
Other Op dit tijdstip werken geeft geen extra vergroot risico op
Table 3.5 continued: Full feedback as given in DOCpass based on filled in answer
Health aspect Screening method Threshold value(s) or answering options Feedback
Fatigue 2. How many full hours have you slept before starting this shift?
< 7 hours of sleep Gemiddeld 7.5 tot 8.5 uur slaap is nodig om optimaal te kunnen functioneren.
U zit hier op dit moment onder.
Neem voldoende rustpauzes tijdens deze dienst Probeer goed geconcentreerd te blijven
En geef zo mogelijk aan collega’s aan als er iets is. > 7 hours of sleep Met het aantal uren dat u dit etmaal heeft geslapen, is er
geen extra risico op suboptimaal functioneren tijdens uw werk.
3. How many hours are you into your current shift?
< 9 hours into current shift Diensten waarbij u tot 9 uur actief bent op het werk hebben geen extra risico op incidenten of het maken van fouten. > 9 hours into current shift Meer dan 9 uur actief zijn op het werk verhoogt het extra
risico op incidenten of het maken van fouten. Pauzeer voldoende
Probeer u goed te blijven concentreren, En eet en drink voldoende.
4. How many hours has it approximately been since your last break?
< 2 hours since last break U pauzeert voldoende tijdens het werk wat geen extra risico op incidenten of het maken van fouten meebrengt.
> 2 hours since last break Langer dan twee uur aan een stuk doorwerken verhoogd het extra risico op incidenten of het maken van fouten.
Table 3.5 continued: Full feedback as given in DOCpass based on filled in answer
Health aspect Screening method Threshold value(s) or answering options Feedback
5. Stanford Sleepiness Scale 1. Feeling active, vital, alert, or wide awake.
2. Functioning at high levels but not at peak; able to concentrate.
U bent nog actief en alert genoeg waardoor u een geen extra risico heeft op incidenten of het maken van fouten tijdens het werk.
3. Awake, but relaxed; responsive but not fully alert. 4. Somewhat foggy, let down. 5. Foggy; losing interest in remaining awake; slowed down.
Uw alertheid kan leiden tot een extra verhoogd risico op incidenten of het maken van fouten tijdens het werk. Probeer alert te blijven door bijvoorbeeld:
Voldoende te drinken
Met collega’s te blijven praten, of Op kauwgom te kauwen.
6. Sleepy, woozy, fighting sleep; prefer to lie down.
U bent slaperig en dit brengt een extra verhoogd risico op incidenten of het maken van fouten tijdens het werk met zich mee. Probeer alert te blijven door bijvoorbeeld: De radio aan te zetten
Met collega’s te praten
En bespreek zo nodig mogelijkheden om taken over te dragen aan collega’s.
7. No longer fighting sleep, sleep onset soon; having dream-like thoughts.
U geeft aan niet meer goed wakker te kunnen blijven, wat een hoog extra risico is voor de patiëntveiligheid tijdens het werk. Probeer goed te blijven concentreren door
bijvoorbeeld:
Met collega’s te blijven praten, of Op kauwgom te kauwen
En probeer zo snel mogelijk te pauzeren of taken over te dragen.
Table 3.5 continued: Full feedback as given in DOCpass based on filled in answer Health
aspect
Screening method Threshold value(s) Feedback
Mood 6. Profile of Mood States (POMS)
Good Neutral Poor
a. Bad tempered In een goed humeur
zijn is nodig om onnodige extra risico’s op incidenten of het maken van fouten te vermijden.
Een enigszins slecht humeur kan van invloed zijn op werk
functioneren.
Probeer te achterhalen wat u dwarszit voor u de OK opgaat in het belang van de patiëntveiligheid
Praat erover met collega’s.
Een slecht humeur kan van invloed zijn op werk functioneren.
Probeer te achterhalen wat u dwarszit voordat u de OK opgaat in het belang van de patiëntveiligheid
Praat erover met collega’s.
b. Exhausted Energiek zijn heeft een
positieve invloed op het uitvoeren van uw werk.
Aan de suffe kant zijn kan ervoor zorgen dat alertheid verminderd wat kan leiden tot incidenten en het maken van (meer) fouten.
Houdt hier rekening mee door: Probeer u goed te blijven
concentreren
Pauzeer en drink voldoende Zet de radio aan
Of blijf met collega’s praten.
Uitgeput zijn gaat gepaard met verminderde alertheid en een verhoogd risico op incidenten of het maken van fouten.
Probeer u goed te blijven concentreren
Pauzeer en drink voldoende Zet de radio aan Of blijf met collega’s
Table 3.5 continued: Full feedback as given in DOCpass based on filled in answer
Health aspect Screening method Threshold value(s) Feedback
Mood Profile of Mood
States (POMS)
Good Neutral Poor
c. Annoyed Niet geërgerd of
geïrriteerd zijn heeft een positieve invloed op het goed
uitvoeren van uw werk.
Enigszins geërgerd of geïrriteerd zijn kan van invloed zijn op hoe u werk uitvoert.
Houdt hier rekening mee om incidenten of het maken van fouten te voorkomen. Probeer te achterhalen wat u
dwarszit voor u de OK opgaat. Haal eens zes keer rustig adem
tijdens uw voorbereiding op de OK Concentreer u op uw komende taak Zet de radio aan
Of praat met collega’s.
Geërgerd of geïrriteerd zijn kan van invloed zijn op hoe u werk uitvoert. Houdt hier rekening mee om
incidenten of het maken van fouten te voorkomen.
Probeer te achterhalen wat u dwarszit voor u de OK opgaat. Haal eens zes keer rustig adem
tijdens uw voorbereiding op de OK Concentreer u op uw komende
taak
Zet de radio aan Of praat met collega’s.
d. Grouchy Goed gehumeurd
zijn heeft een positieve invloed op het goed uitvoeren van uw werk.
Enigszins knorrig of geërgerd zijn kan van invloed zijn op hoe u werk uitvoert. Houdt hier rekening mee om incidenten of het maken van fouten te voorkomen en probeer te achterhalen wat u dwarszit voor u de OK op gaat. Zet de radio aan
Of praat met collega’s.
Haal eens zes keer rustig adem tijdens uw voorbereiding op de OK Concentreer u op uw komende
taak.
Knorrig of geërgerd zijn kan van invloed zijn op hoe u werk uitvoert. Houdt hier rekening mee om
incidenten of het maken van fouten te voorkomen en probeer te achterhalen wat u dwarszit voor u de OK op gaat. Zet de radio aan
Of praat met collega’s.
Haal eens zes keer rustig adem tijdens uw voorbereiding op de OK Concentreer u op uw komende
Table 3.5 continued: Full feedback as given in DOCpass based on filled in answer Health
aspect
Screening method Threshold value(s) Feedback
Mood Profile of Mood
States (POMS) Good Neutral Poor
e. Energetic Energiek zijn heeft een
positieve invloed op het goed uitvoeren van uw werk.
Moe zijn heeft effect op het werk functioneren en alertheid, en kan leiden tot incidenten of het maken van fouten.
Concentreer u op de taak die komen gaat
Pauzeer en drink voldoende om uzelf op te laden, of Zet de radio aan.
Geen energie meer hebben heeft effect op het werk functioneren en alertheid, en kan leiden tot
incidenten of het maken van fouten.
Concentreer u op de taak die komen gaat
Pauzeer en drink voldoende om uzelf op te laden, of Zet de radio aan.
f. Clear headed Helder zijn helpt
onnodige extra risico’s op incidenten of het maken van fouten te vermijden tijdens het werk.
Suf en/of niet heel alert meer zijn geeft een extra verhoogd risico op incidenten of het maken van fouten tijdens het werk. Probeer goed te blijven
concentreren
Pauzeer en drink voldoende tijdens uw dienst
Kauw op kauwgom, of Zet de radio aan.
Niet helder en/of alert zijn geeft een extra verhoogd risico op incidenten of het maken van fouten tijdens het werk. Probeer goed te blijven
concentreren
Pauzeer en drink voldoende tijdens uw dienst
Kauw op kauwgom, of Zet de radio aan.
3.2 DESIGN AND DEVELOPMENT DOCPASS
The actual prototype was developed in HTML and JavaScript based on a set of predefined requirements (see table 3.6). Beside these requirements, heuristic design principles (Jakob Nielsen, 75) were maintained (see figure 5) to implement the content in the best possible way that would be user friendly and
compatible with working flows in practice. For development the Adobe Dreamweaver editor [76] was used and versions of the prototype were discussed in the project group to optimize content and design throughout this process. Decisions taken in this phase were on the type of platform to use for the prototype and the web display.
3.2.1 PLATFORM
The type of platform for the prototype of DOCpass was selected based on the system’s requirements. These requirements demanded that the platform had to try and integrate the following aspects (i) easy access and good availability, (ii) ability to generate personal advices based on input, (iii) ability to (easily)
Table 3.6 Requirements DOCpass
DOCpass has to:
