Cross-coverage in clinical setting: Potential solution for performance improvement

In healthcare, providing care to patients of other physician/colleague in their interim is very common. Other terms used are sign-off or hand-off, however, cross-coverage happens when the regular physician is unable to provide care to his/her patients due to situations other than shift change. In the department of radiation oncology at the University of North Carolina at Chapel Hill, the oncologists provide the best care with high quality and efficiency in treating patients with cancer. Physicians in the department often cover for other physicians in some unavoidable situations.
There is evidence that cross-coverage and last moment clinician changes are often associated with adverse events (look at the paper in the URL: http://www.practicalradonc.org/article/S1879-8500%2813%2900129-X/abstract).

To learn about the experienced mental workload and to measure performance (willingness to approve the plan) during cross-coverage, a simulated environment was designed: radiation treatment planning for a simple brain tumor case. The first scenario of planning represented a cross-coverage scenario and after 48 hours, the physician’s plan the same case, representing a regular-scenario. The tasks involved physicians to review the patient health records from the electronic medical records system, plan the radiation treatment in the radiation planning software (also involves the work of other specialists like dosimetrists etc.) and, approve the plan. NASA Task-Load-Index (TLX) was used as a subjective measure and physiological measure of pupil dilation was used as an objective measure of mental workload. Performance was evaluated using “willingness to approve” the plan for treatment.

Workload increased significantly (almost doubled) during the cross-coverage scenario compared to regular-coverage. Willingness to approve the plan in cross-coverage scenario dropped to 80% compared to regular-scenario (100% approval rate).  Although there was an increase in pupil dilation during cross-coverage scenario, the difference was not statistically significant.

Potential solution for facilitating optimal workload and performance during cross-coverage scenario may include design improvement of electronic medical records and planning systems by incorporating human factors (capabilities and limitations) and user-centered design principles.

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