Complex Socio-technical Systems Research Articles

Feedback on clinical team performance: how does it work, in what contexts, for whom, and for what changes? A critical realist qualitative multiple case study

BackgroundFeedback on clinical performance aims to provide teams in health care settings with structured results about their performance in order to improve these results. Two systematic reviews that included 147 randomized studies showed unresolved variability in professional compliance with desired clinical practices. Conventional recommendations for improving feedback on clinical team performance generally appear decontextualized and, in this regard, idealized. Feedback involves a complex and varied arrangement of human and non-human entities and interrelationships. To explore this complexity and improve feedback, we sought to explain how feedback on clinical team performance works, for whom, in what contexts, and for what changes. Our goal in this research was to present a realistic and contextualized explanation of feedback and its outcomes for clinical teams in health care settings.MethodsThis critical realist qualitative multiple case study included three heterogeneous cases and 98 professionals from a university-affiliated tertiary care hospital. Five data collection methods were used: participant observation, document retrieval, focus groups, semi-structured interviews, and questionnaires. Intra- and inter-case analysis performed during data collection involved thematic analysis, analytical questioning, and systemic modeling. These approaches were supported by critical reflexive dialogue among the research team, collaborators, and an expert panel.ResultsDespite the use of a single implementation model throughout the institution, results differed on contextual decision-making structures, responses to controversy, feedback loop practices, and use of varied technical or hybrid intermediaries. Structures and actions maintain or transform interrelationships and generate changes that are in line with expectations or the emergence of original solutions. Changes are related to the implementation of institutional and local projects or indicator results. However, they do not necessarily reflect a change in clinical practice or patient outcomes.ConclusionsThis critical realist qualitative multiple case study offers an in-depth explanation of feedback on clinical team performance as a complex and open-ended sociotechnical system in constant transformation. In doing so, it identifies reflexive questions that are levers for the improvement of team feedback.

Fatigue as a key human factor in complex sociotechnical systems: Vessel Traffic Services.

Vessel Traffic Services (VTS) are considered a subsystem of people, whose mission is to improve the effectiveness and efficiency of maritime transport within the maritime system. VTS operate as a control system where Vessel Traffic Services Operators (VTSOs) must cope with a complex environment to make up for safe and efficient maritime transport, so it is essential to understand how these operators maintain control through adapting to the uncertain and dynamic environment of maritime traffic. This multidisciplinary study explores how human factors within this complex sociotechnical system, means VTS, play a role in maritime safety, specifically focusing on fatigue, which is considered a key variable for VTSOs' performance. In this context, the research has focused on the assessment of fatigue with psychological and operational instruments to highlight the importance of the human element in CSSs. To study the intra and inter-individual differences in fatigue ratings and their relationships with other personal and environmental variables: mental workload, work shifts, reaction time, and hours of usual sleep. The study was conducted in two of the 19 Spanish Maritime Rescue Coordination Centers (MRCCs) with a sample of 23 active VTSOs (82.14% of the staff). Both objective and standardized subjective measures were used to assess fatigue and associated sleepiness (Borg RPE, Nasa-TLX, Stanford Sleepiness Scale, and Self-Assessment Manikin Scale). A significant positive correlation between fatigue and mental workload was found, being more prevalent in the night shift, which shows a bigger variation in these variables. A significant difference was found in the increase in fatigue experienced throughout the shift depending on the hours of usual sleep, being smaller in the group of subjects reporting to sleep more. The human element is key to maritime safety related to Vessel Traffic Services, so it is of paramount importance to consider certain measures to counteract the negative effects of fatigue. A proper organization of duties on/off periods, assessment of work and rest schedules, and the implementation of fatigue management programs based on sleep education are recommended.

Analysis of safety and security challenges and opportunities related to cyber-physical systems

A cyber-physical system (CPS) is an interconnected physical system that can be monitored, controlled, and operated remotely. A systems-based analysis of CPS is critical for enhancing operational safety and security. Such analysis is particularly important in light of the evolving Fourth Industrial Revolution (Industry 4.0) which is largely driven by CPS, Internet of Things (IoT), algorithmic systems, automation, and smart manufacturing. As a result of industries’ and societies’ growing dependence on CPSs, their safe and secure applications need to be scrutinized to avoid any threats or harm to processes and human lives. In order to achieve this target, the current work analyzes the literature to investigate challenges and opportunities present in the CPSs. The analysis attempts to answer the following Research Questions (RQs): (RQ1) What are the prominent trends in the field of safety and security of CPSs? (RQ2) What are the opportunities in Industry 4.0 technologies related to safety? (RQ3) What characteristics of CPSs are likely to cause safety and security issues? (RQ4) What are the emerging safety and security issues introduced by CPSs? (RQ5) How were these issues addressed in the literature? CPSs can address some traditional safety issues due to characteristics like high efficiency and control. However, a CPS is challenged by heterogeneity, dependencies, complexity, unattended nature, increased machine intelligence, autonomous reconfiguration, and uncertainties. Safety and security challenges include opaque system failure, complex socio-technical system, human-machine interface, cyber-physical attacks, unsecured remote configuration, lack of standards, and resilience. The paper is structured under the following key headings: bibliometric results, opportunities from Industry 4.0 technologies, issues introduced by Industry 4.0 technologies, literature proposed solutions, and research challenges. Based on the assessment of about 900 relevant publications extracted from two databases (Web of Science (WoS) Core Collection and Engineering village (EV)), the documents were categorized into eight major divisions: (i) Safety Opportunities, (ii) Hazardous Characteristics, (iii) Fault Occurrence, (iv) Cyber-physical attacks, (v) Human factors, (vi) occupational Health and safety, (vii) standards, and (viii) Reliability and resiliency. Proactive strategies were classified under four options: identification, evaluation, prevention, and management. The paper also raises some research needs and unanswered questions that require further analysis to address how security and safety mechanisms can introduce more complexity in the system that can lead to new risks. The paper concludes by emphasizing digital process safety as part of the engineering curriculum to address the process industry's need for digital solutions and to make process safety learning a conscious choice.

Project Matrix: a Virtual Experience Platform for RE-Conciling Human Ecology & Urban Ecology

A flashback to previous centuries testifies extraordinary human-lead technological prowess; from the invention of the telescope in the 17th-century, the telephone in 19th-century, the Worldwide-Web and technological revolution of 20th-21st century; it is undeniable that Humans constantly strive to overcome challenges through technological innovation by empowering/advancing humanity. Yet, we’ve witnessed a global disruption by a pandemic that exposed unforeseen weaknesses and exacerbated existing issues (human negligence or not). Suddenly all well-structured and reliable system-organization failed, exposing inadequacies, causing chaos and harmful damages of interconnected components including the flows of people, health, matters, information, economy, politic, materials, communication networks, deadlines, etc. Covid-19 spread across the globe defeated technological advancements. How could that happen in such technological era? Is Human in control of digital evolution or is the technology we invent holding us on leash? Was technology in place to leverage and tackle risks? Where we not prepared to it, or were we focused on the wrong tracks? In any case, whether by failure or negligence, Covid-19 has made history and will continue generating ink flow for decades to come. It is to help address these multi layered-multidimensional and highly complex socio-technical and temporal systems that this project intends to develop a series of applications in alignment with the SDGs. The focus is to blend the capabilities of environment scanning Apps with that of the human habitus-emotions capture, tracing and feedback collector in time and place. It requires advance analytical studies to fully understand interdependencies while respecting the relationships of all subsystems.

Towards a Holistic Life Cycle Costing and Assessment of Factories: Qualitative Modeling of Interdependencies in Factory Systems

Modern factory planning requires a holistic perspective taking economic as well as environmental sustainability over the entire factory life cycle into account. As a complex socio-technical system, the factory life cycle consists of multiple life cycles of the inherent factory elements. A holistic understanding of the individual life cycles and their interdependencies is missing for both planning and operation of a factory. Therefore, the goal is to develop a system understanding about life cycle-oriented factory planning and to analyze the contribution of relevant factory elements to the sustainability of a factory. As a result, a knowledge base for life cycle costing and assessment of the entire factory is established using an impact path model. The qualitative model supports factory planners in deriving planning measures for the sustainable design of a factory and in determining data requirements for the quantitative evaluation of the economic and environmental sustainability of a factory. It shows that the production and logistics concepts essentially define the sustainability potential during planning, while the resulting life cycle behavior of the process facilities and workers is responsible for the majority of costs and environmental impacts of a factory. Factory planners must therefore become aware of the implications of planning decisions on factory operation when developing concepts in the future.

Software Development Practice as Baradian Entanglement

Software development practice is a messy, complicated, and constantly shifting human endeavor. Barad’s concept of “entanglement” helps to theorize complex sociotechnical systems. We are testing the application of this theory to understand and explain software development practices, as our work appears to be the only ethnographic research using Barad in any technology industry. Our continual aim is to understand large-scale, collaborative software development more deeply in practice and to discover appropriate theories that describe our observations and insights. Both authors are experienced software engineers and researchers. Through an ongoing longitudinal ethnographic study at a large Australian software development company, we explore, support, and improve the lived experience and practice of the software developers that work there. Ethnographic insights and an appreciation of the mutual constitution of situated phenomena have expanded over several years into an elaboration of entanglement as a more insightful explanation of software development practice. This research is having a significant impact on the participant developers and organization, including changes in measurement practices, mentoring, knowledge management, and innovation.

Digital Disparities in Patient Adoption of Telemedicine

Telemedicine's growth during the COVID-19 pandemic exposed digital and health disparities in U.S. communities. Public health advocates suggest disparities in healthcare access may be mitigated through free or low-cost broadband. However, prior research shows that many factors influence patient adoption of information technologies; therefore, increasing access to broadband alone is insufficient. This paper advances a patient-centered model of telemedicine (TM) adoption supported by qualitative interview data. The model illustrates that patient adoption of TM is driven by a complex sociotechnical system comprised of technology factors, structural factors underlying the provider's provision of TM, and individual patient factors. Findings highlight the importance of the physical place of the TM visit, the need for experienced TM healthcare workers and technology support for patients, the impact of provider-mandated technology on task-technology fit (TTF), and the strength of the patient-provider relationship. These factors affect patient perceptions of TTF and ultimately TM adoption.

A functional perspective for Intensive Care Unit modelling

Paper aims This study demonstrates the complexity of the patient flow from admission to discharge of an adult Intensive Care Unit (ICU) through the application of the Functional Resonance Analysis Method (FRAM). Originality This paper shows the daily functioning of the patient flow, shedding light on the high levels of interdependence and variabilities in Complex Sociotechnical Systems. Research method The research was developed according to the four steps for FRAM analysis. Sources of evidence involved empirical data collection in a leading teaching public hospital in Brazil. Main findings There were identified 34 functions performed mainly by caregivers and support staff. Five instantiations were described to illustrate the functional resonance scenarios caused by the variability propagation across the functions. Implications for theory and practice Limitations of this study and suggestions for future research are pointed out. The resulting model is a basis for context understanding for ongoing and following studies.

Simulation of research and development collaborations as complex socio-technical systems using a hybrid of agent-based modelling and system dynamics

Simulation of research and development collaborations as complex socio-technical systems using a hybrid of agent-based modelling and system dynamics

The rise of digitalisation and automation in the shipping industry and their impacts on training and system safety

The ubiquitous application of digitalisation and automation within the maritime shipping industry will create disruptions that will have profound effects on how work is performed in the industry. The practice of safe navigation will require an evolution and subsequent evolvement of how operators and technologies interact in a complex sociotechnical system if a better understanding of system safety is to be achieved. Predictions of how actors and agents in the same workspace will emerge. This paper focuses on the current levels of automation prevalent in the navigation sector, a futuristic prediction and foresight of challenges related to the emergence of technologies, automation and artificial intelligence, and the competencies required related to the training of future seafarers.

Simulation of research and development collaborations as complex socio-technical systems using a hybrid of agent-based modelling and system dynamics

Simulation of research and development collaborations as complex socio-technical systems using a hybrid of agent-based modelling and system dynamics

Using Digital Biomarkers for Objective Assessment of Perfusionists' Workload and Acute Stress During Cardiac Surgery.

The cardiac operating room (OR) is a high-risk, high-stakes environment inserted into a complex socio-technical healthcare system. During cardiopulmonary bypass (CPB), the most critical phase of cardiac surgery, the perfusionist has a crucial role within the interprofessional OR team, being responsible for optimizing patient perfusion while coordinating other tasks with the surgeon, anesthesiologist, and nurses. The aim of this study was to investigate objective digital biomarkers of perfusionists' workload and stress derived from heart rate variability (HRV) metrics captured via a wearable physiological sensor in a real cardiac OR. We explored the relationships between several HRV parameters and validated self-report measures of surgical task workload (SURG-TLX) and acute stress (STAI-SF), as well as surgical processes and outcome measures. We found that the frequency-domain HRV parameter HF relative power - FFT (%) presented the strongest association with task workload (correlation coefficient: -0.491, p-value: 0.003). We also found that the time-domain HRV parameter RMSSD (ms) presented the strongest correlation with perfusionists' acute stress (correlation coefficient: -0.489, p-value: 0.005). A few workload and stress biomarkers were also associated with bypass time and patient length of stay in the hospital. The findings from this study will inform future research regarding which HRV-based biomarkers are best suited for the development of cognitive support systems capable of monitoring surgical workload and stress in real time.

Mapping socio-technical dependencies to enable the successful adoption of collaborative robots in industry

Collaborative robots (cobots) allow for combining complementary strengths of humans and robots. However, this close human-cobot interaction creates a highly complex socio-technical system. This is a key adoption and integration challenge as it complicates an understanding of dependencies between cobots and their surrounding workplace: while a cobot needs to fit to the product to be manipulated, the human operator and the workplace, those three domains also need to be adjusted to allow for a successful cobot use. This paper presents a matrix-based approach to analyze dependencies between the four domains; (1) cobot, (2) product, (3) human/operator, and (4) workplace.

The Standardization of the Emergency Department Response to Chemical, Biological, Radiological, and Nuclear (CBRN) Events: Human Factors/Ergonomics Approach.

To provide standardized recommendations for the emergency department (ED) response to chemical, biological, radiological, and nuclear (CBRN) events by combining the human factors/ergonomics method of hierarchical task analysis with the theoretical framework for Work as Imagined versus Work as Done. Document analyses were used to represent CBRN response operational procedures. Semi-structured interviews using scenario cards were carried out with 57 first receivers (ED staff) to represent CBRN practice at 2 acute hospitals in England. Variability existed in general organizational responsibilities associated with the CBRN response. Variability was further evident in top level CBRN tasks and CBRN phases at both EDs. Operational procedures focused on tasks such as documentation, checking, and timing. CBRN practice focused on patient needs through assessment, treatment, and diagnosis. The findings provide top-down and bottom-up insights to enhance the ED CBRN response through standardization. The standardized CBRN action card template embeds the choice approach to standardization. The standardized CBRN framework implements the streamlined categorization of CBRN phases. Work as Imagined versus Work as Done is a useful theoretical framework to unpack a complex sociotechnical system, and hierarchical task analysis is an effective system mapping tool in health care.

TEORIA ATOR-REDE PARA AS CIÊNCIAS DA SEGURANÇA: REAGREGANDO ELEMENTOS SOCIAIS E TÉCNICOS

ABSTRACT Recent studies suggest challenges in developing safety science: broadening perspectives and methodologies for sociotechnical work comprehension and incentives so that the complexity effects can be analyzed with greater depth and safety research can become politically oriented in its models. This study explores the contributions of Actor-Network Theory as a methodological resource to reassemble human and non-human elements in safety science research, especially when considering the dynamic reality, variability, and uncertainty characteristic of complex sociotechnical systems. In light of the theoretical aspects of the Actor-Network Theory, such as controversies, political ontologies, and enactment, we discuss possibilities for the cartography of controversies in safety science studies. The discussion contributes, thus, with new methodological connections to research in safety science, exploring associations and new positions among different realities in the field.

Adding Resilience to Hospital Bed Allocation, using FRAM Ralph MacKinnon, Jacob Barnaby, Nomoto Hideki, Rees Hill and David Slater

Modelling complex sociotechnical systems to better understand and optimise their operation has proved a challenge and many methodologies have been put forward to use in what has been called model-based system engineering (MBSE). The appropriateness and availability of the Functional Resonance Analysis Method as a suitable candidate has been tested here, in the context of developing a methodology that can be applied currently, and in an actual real system requiring taking life and death decisions on an informed understanding of the factors and risks involved. The allocation of scarce critical care beds in hospitals is a clear example of where a better understanding of the system and a way of feeding the decision makers with crucial information on numbers and trends could help optimise very challenging responsibilities. By building on recent developments by Hill of Hollnagel’s paradigm shifting approach, this paper has laid out how FRAM system modelling can provide not only the prediction and correction mechanism provided by the new machine learning FRAM facility demonstrated by Nomoto but can add resilience to the critical decision making involved. It puts forward the case that it is certainly worth pursuing and developing further.

Shape Matters: A Neglected Feature of Medication Safety : Why Regulating the Shape of Medication Containers Can Improve Medication Safety.

This paper aims to highlight how to reduce medication errors through the implementation of human factors science to the design features of medication containers. Despite efforts to employ automation for increased safety and decreased workload, medication administration in hospital wards is still heavily dependent on human operators (pharmacists, nurses, physicians, etc.). Improving this multi-step process requires its being studied and designed as an interface in a complex socio-technical system. Human factors engineering, also known as ergonomics, involves designing socio-technical systems to improve overall system performance, and reduces the risk of system, and in particular, operator, failures. The incorporation of human factors principles into the design of the work environment and tools that are in use during medication administration could improve this process. During periods of high workload, the cognitive effort necessary to work through a very demanding process may overwhelm even expert operators. In such conditions, the entire system should facilitate the human operator's high level of performance. Regarding medications, clinicians should be provided with as many perceptual cues as possible to facilitate medication identification. Neglecting the shape of the container as one of the features that differentiates between classes of medications is a lost opportunity to use a helpful characteristic, and medication administration failures that happen in the absence of such intentional design arise from "designer error" rather than "user error". Guidelines that define a container's shape for each class of medication would compel pharmaceutical manufacturers to be compatible and would eliminate the confusion that arises when a hospital changes the supplier of a given medication.

Maximizing student potential: Lessons for pharmacy programs from the patient safety movement

Higher education institutions (HEIs), including pharmacy programs, are experiencing growing pressure from the public and policy makers to develop student-centered learning experiences that meet societal needs. While HEIs may have in-house initiatives to meet such challenges, there are also opportunities for cross-domain learning and application of useful concepts from other sectors. One such sector that lends itself to cross-domain learning is the healthcare industry. Like HEIs, the healthcare industry has been experiencing pressure from its stakeholders, in this case, to address patient safety gaps. These forces intensified at the turn of the century leading to the emergence of what is now known as the patient safety movement, which enabled increased advocacy, education, and research to reduce healthcare-related harm. Despite persistent challenges, a key achievement of the patient safety movement has been application of a systems framework to understand and solve patient safety gaps. That is, patient safety gaps are often a result of system defects rather than isolated acts of individual workers operating in a complex social and technical work setting (often referred to as sociotechnical system). Commonly used systems frameworks describe a sociotechnical system through its components: 1) structure (e.g., people, tools/technology, physical workspaces); 2) processes (e.g., medication administration); and 3) outcomes (e.g., medication safety, patient satisfaction). At their core, both HEIs and healthcare organizations are complex sociotechnical systems that organize their structures to support specific processes - learning in HEIs and patient safety in healthcare - to ultimately improve outcomes for students and patients, respectively. This paper describes parallels between HEIs and the healthcare domain to illustrate how patient safety concepts and practices from healthcare can be adapted to HEIs in order to enhance educational structures, processes, and learning outcomes.

Behavioural Change as a Domestic Heat Pump Performance Driver: Insights on the Influence of Feedback Systems from Multiple Case Studies in the UK

Heat pumps (HPs) are seen as an increasingly important technology able to contribute significantly towards the decarbonisation of the domestic stock in the UK. However, there appears to be a performance gap between predicted and real-life HP performance, with several studies highlighting the need to include the HP’s interaction with users when examining their performance. This study examines the role of user behaviour in mitigating this performance gap from a systems perspective. A sample of 21 case studies was selected from 700 domestic HPs monitored across the UK via the government’s Renewable Heat Premium Payment Scheme for the collection of qualitative and quantitative socio-technical data. The application of systems thinking facilitated the identification of the underlying interactions between the HP system and its users. The systems analysis revealed that HP performance relies on complex socio-technical system interactions, including behavioural patterns, and that enabling feedback information processes can have a significant impact on user behaviour. The study enabled a deeper perspective on performance influencers relating to behavioural patterns and achieved new insights into the requirements for well-performing HPs. These findings have important implications for policy makers, installers and manufacturers of HP systems and their users.

Safety‑II: asystemic approach for an effective clinical risk management

The healthcare system is an example of acomplex sociotechnical system where the goal is the best possible individual treatment together with the cost-effective use of modern technology. Working in anesthesia requires medical knowledge as well as manual skills and the use of specialized technical equipment in an interdisciplinary and interprofessional setting. The susceptibility to errors and adverse events, especially in the care of critically ill patients, is high.In order to avoid unintentional hospital-induced patient harm, the healthcare system has recently taken the path of prescribing the best possible care for alarge number of patients with the help of evidence-based guidelines and specific algorithms or instructions for action. Patient safety is defined accordingly as astate in which adverse events occur as rarely as possible (Safety‑I).Following this approach clinical risk management is defined as the purposeful planning, coordination, execution and control of all measures that serve to avoid unintended hospital-induced patient harm or to limit its effects. For this purpose, the focus has recently been placed on instruments such as Critical Incident Reporting Systems (CIRS) or Morbidity and Mortality Conferences (M&MC); however, it is increasingly recognized that adverse events in complex sociotechnical systems such as the healthcare system arise situationally from the interaction of numerous components of the system. The effectiveness of CIRS and M&MC is limited because they do not comprehensively take situational effects into account. Thus, only selective changes are possible which, however, do not imply asustainable improvement of the system. Newer approaches to strengthening safety in complex sociotechnical systems understand positive as well as negative events as being equally caused by the variable adaptation of behavior to daily practice. They therefore focus on the majority of positive courses of treatment and the necessary adaptations of the health professionals involved in daily practice (Safety‑II). In this way, the adaptability of the system under unexpected conditions should be increased (Resilience Engineering). Taking this systemic approach into account, the Functional Resonance Analysis Method (FRAM) offers avariety of possibilities for the prospective analysis of acomplex sociotechnical system or for retrospective incident analysis through modelling of actual everyday actions (work as done). Through interviews with the health professionals involved, document analyses and work inspections, processes and their functions as well as the associated variability are assessed and graphically presented. The FRAM models the collected information of the process as complexes of interconnected functions represented by hexagonal symbols. Each corner of the hexagon represents agiven aspect, which together form the properties of the function (input, output, precondition, resource, time, control). Through this visualization and evaluation of the interview results, the actual everyday actions (work as done) can be compared with the predefined ones (work as imagined). The evaluation of the variability found in this way enables the strengths and weaknesses of processes to be uncovered. As aresult, specific measures can be derived to strengthen the system. Increased consideration of the Safety‑II approach within clinical risk management can be avaluable addition to existing clinical risk management methods.