Making it easier to do the right thing

Quality Education for a Healthier Scotland

Multidisciplinary

Michelle ClarkTraining and Research Officer

(Health Psychology)NHS Education for Scotland

michelle.clark@nes.scot.nhs.uk

Mark JohnstonTraining and Research Officer

(Patient Safety)NHS Education for Scotland

mark.johnston@nes.scot.nhs.uk0131 656 3258

Workspace

Culture

Organisation

TaskTeamwork

Impact on behaviours and abilitiesAdapted from Catchpole

@markjohnston71

Multidisciplinary

Human Factors case study – Hand hygiene behaviours of final year

medical students

Multidisciplinary

Pilot study – what we did

• Final year medical students at University ofDundee Medical School

• Mixed methodology

Quantitative (n=30)

Questionnaire assessing

• Predictors of HH behaviour

•Barriers & levers to HH behaviour

Qualitative (n=9)

Based on students’ final year ‘ward simulation exercise’

assessment video

‘Self-explanatory’ interview

Categorical content analysis using HF & Health Psychology

theory frameworks.

Multidisciplinary

Results – Questionnaire Predictors of behaviour

Attitudes

Normative beliefs

Perceived behavioural

control

Behaviour intentions

Behaviour

Theory of Planned Behaviour (Ajzen & Fishbein, 1980)

Multidisciplinary

Results – QuantitativeBarriers & Levers

(Theoretical Domains Framework (TDF) Michie et al 2008)

• The higher the number of barriers, the less HH behaviour is carried out

• Compared TDF domains based on levels of compliance (high or low)

Knowled

skills

Profes

l Role

Beliefs

abilit

Beliefs

Motiva

tion &

Memory

ttenti

Enviro

Social

Emotion

Action

s02468

101214161820

Low ComplianceHigh Compliance

** **Mean

scores

Multidisciplinary

Results – Qualitative‘Self-explanatory’ interview

Observable HH behaviour low (despite high self reported HH)

Individual factors

Positive impact• Attitudes & beliefs (capabilities & consequences of HH)•Motivation

Negative impact•Stress & anxiety•Human cognition & memory (mental load, dual processing, primacy effects

Task related factors

Negative ImpactMultiple tasks•Switching between multiple patients•Changing symptom presentation•Problem solving nature of tasks

Environment factors

Positive Impact•Multiple gel bottles •Prominent location

Negative Impact•Layout of ward•Layout of paperwork/forms.

Multidisciplinary

HH Pilot study (cautious) conclusions• Clear intention-behaviour gap (self report & observed HH

behaviour)

• Cognitive factors & beliefs about capabilities are barriers to HH (in this group)• Making several decisions within a high pressure

situation lead to high cognitive load which negatively affects memory – automaticity not achieved

• Need to believe you are capable of performing HH

• Attitudes towards HH & Social influence (especially from influential staff members) can predict HH behaviour

• Primacy effect evident in practice of WHO 5 moments, but not recency effect (forgot moments 4&5).

Multidisciplinary

Implications...

Teaching of Hand Hygiene behaviour

• Impact of stress/anxiety and cognitive load on HH behaviour & make behaviour automatic even in stressful situations

• Other prompts to remind & encourage habits at more of the WHO moments.

Multidisciplinary

Bad people?

Error occurs due to Systemic and Systemic induced Individual failure

Negligence is not the same as error, both may result in harm

So, some thoughts on why…?

Multidisciplinary

105 HF facilitators workshop Sept 11

MultidisciplinaryYou’re amazing!

MultidisciplinaryWhy do we make mistakes?

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

Multidisciplinary

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

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

Driving 64 mph-the illegal-

normal space

Driving75 mph – the ‘illegal-illegal’ space (for almost all of us!)

IndividualPressures

PerceivedVulnerability

Belief inSystems-guidelines

Accident

Driving 100 mphillegal for all Borderline Tolerated

Conditions of Use

Adapted from Rene Amalberti

Normalisation of Deviance

Multidisciplinary

Even experts make mistakes

Multidisciplinary

Human FactorsA common language

“Enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities and application of that 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)

Multidisciplinary

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

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

Reason

Multidisciplinary

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

2 x 2=

17 x 379 =

4…System 1

6443…System 2.

Kahneman 2012

Multidisciplinary

Card suit change game

Groups of three

• 1 Person deals cards, turning them face up in rapid succession and estimates the passing of timeIf you deal all the cards deal them again

• 1 person estimates the passing of time with no aid and counts the number of times the cards change suit.

• 1 person times the activity using an aid and then focuses only on recording the suit changes

When told to finish, separately record the time and number of suit changes and compare your results

Multidisciplinary

Where can we start?

(Flin, Patey 2012)

Work/Environment-Work environment

and hazards(ergonomics)

Multidisciplinary

‘We cannot change the condition of those who do the work, but we can change 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.

Multidisciplinary

Where can we start?

Organisational/ Management

-Safety Culture-Managers’ Leadership

-Organisation communication

(Flin, Patey 2012)

Multidisciplinary

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

Multidisciplinary

Silo working?

Doctors

Managers

Nurses

What is your culture?

Multidisciplinary

Hierarchies?

Multidisciplinary

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

Our learned behaviour is to blame an individual

Society, peers, media

Imperfect System

Our colleagues, ourselves?

Multidisciplinary

Where can we start?

(Flin, Patey 2012)

Workgroup/Team-Teamwork

-Team Leadership

Multidisciplinary

Lessons for Leadership inchanging culture

Culture change and continual improvement come from what leaders do, through their commitment, encouragement, compassion and modelling of appropriate behaviours.

Berwick Report 2013

Multidisciplinary

Where can we start?

(Flin, Patey 2012)

Workgroup/Team

Structures & processes

MultidisciplinaryExamples in healthcare…

• Prescribing and dispensing

• Hand-over/hand-off information

• Movement of patients

• Order of tests

• Preparation of medication

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

Multidisciplinary

Making it easier to do the right thingPDSA example: Christopher

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

Toilet training

Multidisciplinary

PDSA templateDescribe 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

Multidisciplinary

Example: DSADoChristopher thought the demonstration amusing and ignored it

Study0% compliance with the new process0% reliability level

ActSeek out ideas, develop new test cycle.

Multidisciplinary

Example: next PDSA cycle

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

A Human Factors approach!

Multidisciplinary

Making it easier to do the right thing

Michelle ClarkTraining and Research Officer

(Health Psychology)NHS Education for Scotland

michelle.clark@nes.scot.nhs.uk

Mark JohnstonTraining and Research Officer

(Patient Safety)NHS Education for Scotland

mark.johnston@nes.scot.nhs.uk0131 656 3258

Workspace

Culture

Organisation

TaskTeamwork

Impact on behaviours and abilitiesAdapted from Catchpole

@markjohnston71

Making it easier to do the right thing

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