introduction to human factors - nes...aggregation of marginal gains • small improvements in a...

Multidisciplinary

Introduction to Human Factors

Mark JohnstonTraining and Research Officer

(Patient Safety)

Workspace Culture

Task Teamwork

Quality Education for a Healthier Scotland

(Patient Safety)NHS Education for Scotland

[email protected] 656 3258

Organisation

Behaviours and AbilitiesAdapted from Catchpole

@markjohnston71

MultidisciplinaryWhy do we make mistakes?

The system may be set up to fail

‘every system is perfectly designed to achieve the


‘every system is perfectly designed to achieve the results it gets’

Peter Senge.

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45 HF facilitators workshop Sept 11

MultidisciplinaryYour amazing!


MultidisciplinaryWhy do we make mistakes?

• Sometimes we do the wrong thing, consciously and


• Sometimes we do the wrong thing, consciously and sub-consciously

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Indi

vidu

al A

uton

omy

Driving 64 mph-the illegal-

Driving75 mph –the ‘illegal-illegal’space (for almost all

VE

RY

UN

SA

FE

SP

AC

EIndividualPressures

PerceivedVulnerability

Driving 100 mph

illegal for all Borderline Tolerated

Conditions of Use


<1% 5% 50% 80% 100% percent of drivers

PERFORMANCE

The posted speed limit is 60 mph- the ‘legal’ space

-the illegal-normal space

almost all of us!)

VE

RY

UN

SA

FE

SP

AC

E

Vulnerability

Belief inSystems-guidelines

Adapted from Rene Amalberti

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Human FactorsA common language

“Enhancing clinical performance through an understanding of theeffects of teamwork, tasks, equipment, workspace, culture andorganisation on human behaviour and abilities and application ofthat knowledge in clinical settings” (Catchpole 2010)


“Making it easy to do the right thing” (Bromiley 2011)

Organisational/ Management-Safety Culture

-Managers’ Leadership-Organisation communication

Work/Environment-Work environment

and hazards(ergonomics)

Workgroup/Team-Teamwork

structures & processes-Team Leadership

Individual Worker-Cognitive skills

•Situation awareness•Decision making

- Personal resources•Management of stress•Management of fatigue

(Flin, Patey 2012)

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Even experts make mistakes


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Two examples of our brains making errors

• Multi-tasking• Task focus


• Task focus

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Multi-tasking - Our lazy brains would rather default to system 1

2 x 2 = 4…System 1


17 x 379 = 6443…System 2.

Now try and multi-task - do an equally difficult math problem and walk

MultidisciplinaryThe amazing colour changing card trick


http://www.youtube.com/watch?annotation_id=annotation_262395&feature=iv&src_vid=voAntzB7EwE&v=v3iPrBrGSJM

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The first lesson in reducing avoidable harm is the realisation that we will and do make mistakes

‘It’s the downside of having a brain!’


a brain!’Reason

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Where can we start?



(Flin, Patey 2012)

Work/Environment-Work environment

and hazards(ergonomics)

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‘We cannot change the condition of those who do the work, but we can change the conditions within which they work’


the conditions within which they work’

Reason J. BMJ. 2000 March 18; 320(7237): 768–770.

MultidisciplinaryEveryone, everywhere, every time

Good human factors design in health care accommodates everyone


Not just the calm, rested experienced healthcare worker

But also the inexperienced health-care worker whomight be stressed, fatigued and rushing.

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Where can we start?



Organisational/ Management-Safety Culture

-Managers’ Leadership-Organisation communication

(Flin, Patey 2012)

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‘We cannot change the condition of those who do the work, but we can change the culture within which they work’


the culture within which they work’

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Admin

Nurses

What is your culture?

Quality Education for a Healthier ScotlandSilo working?

Dentists

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Hierarchies?

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Do we pay attention to the Swiss cheese or do we blame?

Our learned behaviour is to blame an individual

Society


System

End point (Dental Colleagues)?

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Where can we start?



(Flin, Patey 2012)

Workgroup/Team-Teamwork

-Team Leadership

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Lessons for Leadership inchanging culture

Culture change and continual improvement come fromwhat leaders do, through


what leaders do, through their commitment, encouragement, compassion and modelling of appropriate behaviours.

Berwick Report 2013

MultidisciplinaryTeam communication and culture

‘The task of communication between health providerscan be complicated… an effective team is one wherethe team members, including the patient,


the team members, including the patient,communicate with one another to optimise patientcare.’

WHO Multi-Professional Curriculum Guide Content Summary

‘Being an effective team player’

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Different mental models?

Jaap video


MultidisciplinaryHudson Bay

An example of great communication that saved lives.


communication that saved lives.

http://www.youtube.com/watch?v=_QazS0uo-eg

��

MultidisciplinaryTake a moment to reflect and discuss

What stood out for you?

• Crew had never flown together before• Structured communication/calm


• Structured communication/calm• Checklists used• Errors still crept in• Others??

��

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So... Teams:

• Work together

• Deliver services

• Mutually accountable

• Share goals


• Share goals

• Interdependent in their accomplishment

• Integrating is the responsibility of all.

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Characteristics of a High Performance Team

1. Clear Objectives2. Encouragement of Participation3. Emphasis on Quality4. Support for Innovation5. Communication


5. CommunicationBorrill et al

MultidisciplinarySBAR

• Situation• Background


• Assessment• Recommendation.

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Where can we start?



(Flin, Patey 2012)

Workgroup/Team

Structures & processes

MultidisciplinaryExamples in healthcare…

• Prescribing and dispensing

• Hand-over/hand-off information

• If all of the processes associated with these


information

• Movement of patients

• Ordering of tests

• Preparation of medication

associated with these tasks make sense and become easier for the ‘human’ to comply with, then patient safety will improve.

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Systems thinking - The patients perspective?

•Value for the patient

•Hand-offs

Organisational/departmental boundaries

A B C D E

Emergency care process


•Accountability for the end-to-end experience

•Job roles

Diagnostic process

Emergency care process

Treatment process

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Improved reliability of process = Improved Outcomes

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Ventilator Associated Pneumonia – Forth Valley ICU


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151 147 262

609+ Days

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Change is a wicked problem!

OK, I’m ready for a change now…any time would be

fine!


“Nobody really looks forward to change, except a wet baby!”

Participant in a QI Workshop, 2006

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A model for learning and changeA mechanism to generate questions

Lots of questions to help frame the problem and generate ideas


Test our idea on a small scale to learn as we go

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The PDSA Cycle for Learning and Improvement

What changes are tobe made for the

PlanActObjective, questions and predictions (why)Plan to carry out the cycle (who,


be made for thenext cycle?

Carry out the planDocument problemsand unexpectedobservationsBegin analysis of the data

Complete the

analysis of the dataCompare data to

predictionsSummarise what

was learned

DoStudy

the cycle (who, what, where, when)

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PDSA example: Christopher

Christopher to urinate into the

Aim:


urinate into the toilet bowl 100% of the time by 30th June 2010.

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PDSA template

Describe your first (or next) test of change:

Person responsible

When to be done

Where tobe done

Demonstrate the correct way to urinate into the bowl and indicate the negative aspects of missing the bowl

Me tonight Downstairs toilet


��

List the tasks needed to set up this test of change

Person responsible

When to be done

Where to be done

Christopher available Me tonight Downstairs WC

Predict what will happen when the test is carried out

What will determine if prediction succeeds

Christopher will show understanding of process and execute correctly

The floor will be dry

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Example: DSADo

Christopher thought the demonstration amusing and ignored it

Study

0% compliance with the new process


0% compliance with the new process

0% reliability level

Act

Seek out ideas, develop new test cycle.

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Example: next PDSA cycle


http://www.amazon.co.uk/toilet-training-target-stickers-Happeedays/dp/B002GZAWUK/ref=pd_sim_by_3

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The value of ‘failed’ tests

“I did not fail one thousand times; I found one thousand ways how


one thousand ways how not to make a light bulb.”

Thomas Edison

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Aggregation of marginal gains

• Small improvements in a number of different aspects of what we do can have a huge impact to the overall

Don’t try to fix the whole system!


to the overall performance of the team

Sir Dave Brailsford - Performance director of British Cycling and the

general manager of Team Sky.

Improve 100 things by 1%

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He is a real dentist!


Thanks for listening!

@markjohnston71

introduction to human factors - nes...aggregation of marginal gains • small improvements in a...

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