The SEIPS 3.0 model is proposed as a comprehensive framework for integrating Human Factors and Ergonomics (HFE) into healthcare quality and patient safety improvement, particularly as healthcare delivery becomes increasingly distributed across space and time. It expands upon previous iterations of the SEIPS model by introducing the crucial concept of the patient journey.
Here’s a more detailed breakdown:
Evolution of the SEIPS Model
- Original SEIPS Model (2006): This initial model aimed to integrate the work system model by Smith and Carayon with Donabedian’s (1988) Structure-Process-Outcome (SPO) model for healthcare quality. The “structure” component of SPO was expanded to include the work system model (elements and their interactions), and the “outcome” component distinguished between patient outcomes (e.g., patient safety) and worker outcomes (e.g., quality of working life). The “process” component, however, was challenging to conceptualize and was interpreted in various ways, often focusing on “what is actually done in giving and receiving care”.
- SEIPS 2.0 Model (2014): This updated version further clarified the role of the external environment, expanded on feedback loops, and described the active and adaptive role of individuals at the core of the work system. SEIPS 2.0 helped in understanding individual and collaborative work among clinicians, patients, and caregivers, highlighting how different work system configurations influence patient, clinician, and organizational outcomes. It also emphasized adaptation mechanisms in the feedback loops between outcomes and work systems.
- Need for SEIPS 3.0: While previous models advanced understanding, the increasing distribution of care over space and time necessitated an evolution of the “process” component. The traditional focus on discrete “tasks” or even single “care processes” within a specific setting was insufficient to address the complexities of modern healthcare, especially with the rise of chronic conditions.
The Core of SEIPS 3.0: The Patient Journey
SEIPS 3.0 addresses this gap by expanding the “process” component to explicitly incorporate the concept of the patient journey.
- Definition: The patient journey is defined as the “spatio-temporal distribution of patients’ interactions with multiple care settings over time“. The National Academies of Sciences, Engineering and Medicine (NASEM) defines it similarly as “the myriad interactions that patients have with the health care system, health care providers (formal and informal), and families and friends and among themselves,” occurring “over time and across multiple health care settings, such as clinics and hospitals, and within communities”.
- Rationale and Importance:
- Care Coordination Challenges: The expanded focus to the patient journey is a direct response to growing challenges in care coordination, particularly for the large percentage of the population with chronic conditions. Poor care coordination leads to negative outcomes like preventable hospital admissions and lack of follow-up care.
- Beyond Single Encounters: Improving care coordination requires moving beyond the typical focus on a patient’s single healthcare encounter. Instead, it necessitates understanding a patient’s journey across and between multiple healthcare delivery organizations and their interactions with various stakeholders (e.g., community organizations, family). Care unfolds across multiple settings over time, including activities performed at home, not just in clinical settings.
- Understanding “Work” in Care Coordination: It highlights the need for a deep understanding of the actual work involved in coordinating care, including the distributed care team members and their interdependent activities over time.
- Focus on Patient Experience: A key component of examining the patient journey is the focus on the patient experience. Therefore, safety initiatives must incorporate the perspectives of patients, their families, and caregivers.
- SEIPS 3.0 Sociotechnical Systems Approach: As shown in Fig. 4 (from the source), SEIPS 3.0 models the patient journey as a temporal series of interconnected work systems.
- It differentiates between the “sharp end” (the local context or work system where patients interact with frontline care team members like caregivers and clinicians) and “blunt end” influences (larger socio-organizational contexts like hospitals or the home environment).
- These work systems are continuously adaptive to changes in the external environment (e.g., laws, regulations) and internal contexts (e.g., technologies, management changes).
- The model emphasizes that looking at only one work system at a single point in time is limiting; understanding the patient journey requires considering these temporal changes, adaptations, and patient navigation among different organizations.
- Like previous SEIPS models, SEIPS 3.0 includes feedback loops from outcomes (patient safety, caregiver burden, clinician burnout, organizational performance) back to the socio-organizational contexts and local work systems, representing learning and continuous improvement mechanisms.
- Illustrative Example (Kathy’s Story): The article uses a fictional patient, Kathy, to illustrate the model’s application. Kathy’s journey involves transitions across multiple healthcare organizations (rural ED, tertiary hospital, skilled nursing facility, physical/occupational therapy clinic). Each step involves interactions between Kathy, her family, and professionals within a larger organizational context. Crucially, transition work at the interfaces between these organizations represents significant opportunities for vulnerabilities (e.g., information not transferred correctly) as well as for error recovery and resilience. An in-depth analysis of these local and organizational system layers and their interfaces is necessary to identify patient safety issues along the entire journey.
HFE Challenges for Human-Centered Design of the Patient Journey
Designing and improving the patient journey presents several significant challenges for HFE researchers and professionals.
- Multiple Perspectives in Human-Centered Design:
- Improving the patient journey requires redesigning multiple interconnected work systems and their interfaces, involving a diverse array of people from different organizations and backgrounds.
- Key stakeholders include patients, caregivers, clinicians from various settings (hospital, primary care, emergency, pharmacy, long-term care, home health), and community entities.
- Managing these multiple, potentially conflicting perspectives (e.g., differing roles, needs, constraints, status differentials between patients and professionals) is a major challenge in participatory collaborative system design.
- Genuine Participation in Human-Centered Design:
- Human-centered design (HCD) of the patient journey must incorporate meaningful participation of relevant stakeholders. HCD goes beyond user-centered design by considering all stakeholders, not just the “patient-user”.
- Implementing participatory design methods is difficult given the diverse, often geographically distributed, and varying schedules of stakeholders.
- A multi-layer approach to participation may be necessary, involving an intervention team of key representatives and mechanisms for input from a wider range of stakeholders (e.g., interviews, surveys).
- The concept of “citizen science” offers a framework for different levels of patient and caregiver involvement:
- Contributory projects: Patients help with data collection (e.g., keeping diaries of their experiences, recording barriers/facilitators).
- Collaborative projects: Patients assist with data analysis and interpretation.
- Co-created projects: Patients and caregivers are involved in all phases and aspects of the project.
- HFE professionals are tasked with developing and testing these genuine participatory methods to fully engage all stakeholders in improving the patient journey.
- Working at the Interface:
- The patient journey fundamentally involves work occurring at organizational, geographical, cultural, and temporal boundaries. Patients “travel” through multiple healthcare organizations (e.g., ED, hospital, specialist offices, long-term care facilities), which may have distinct structures, processes, and cultures, and even be in different geographical regions or time zones.
- Understanding safety along the patient journey requires considering these complex boundaries.
- Example (Medication Management): A study by Werner et al. (2017) highlighted the distributed work of medication management during transitions from hospital to home health care for older adults. This involved multiple individuals in loosely-coupled teams across different organizations. “Boundary spanners” (e.g., hospital- and home-based staff) played a critical role in addressing and working around barriers in communication and information management, often performing tasks beyond their formal job descriptions.
- Without focusing on these interfaces and boundaries, critical system properties and barriers would not be identified. Therefore, HFE professionals need to develop skills, knowledge, and abilities to become “competent boundary spanners,” including cultivating interpersonal relationships, communication skills, political skills, and an understanding of system interdependencies.
- Temporal Analysis: This challenge involves understanding how system barriers and facilitators propagate along the patient journey over time, and how resilience emerges.
In essence, SEIPS 3.0 provides a robust sociotechnical systems lens to analyze and design the complex, distributed nature of patient care, aiming to improve patient safety by focusing on the entire patient journey rather than isolated healthcare encounters.
Reference: Carayon, P., Wooldridge, A., Hoonakker, P., Hundt, A. S., & Kelly, M. M. (2020). SEIPS 3.0: Human-centered design of the patient journey for patient safety. Applied Ergonomics, 84, 103033. https://doi.org/10.1016/j.apergo.2019.103033
