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Delivering health care is complex and
challenging and fraught with risks to
patients. It is inevitable that things will
go wrong. Boards have a critical role
to play in relation to patient safety
because they set the agenda, the level
of investment, the culture and the
strategy for safety in their
organisation. Health care is a risky
business and MIAA believes it is
important to be candid and open
about patient safety if we are going to
make any progress around the issues
identified by the Francis Inquiry.
Human factors, is an established
scientific discipline that has been
systematically integrated into other
safety critical industries like aviation,
oil and gas production, rail and
nuclear power generation. Within
these industries integration of human
factors principles and practices has
reduced risk and led to the design of
error tolerant systems.
In 2013, the National Quality Board
issued a concordat, ‘Human factors in
Healthcare.’ The concordat
represented a commitment from the
Department of Health, NHS England,
Health Education England, Care
Quality Commission, National Institute
for Health and Care Excellence, Public
Health England, NHS Leadership
Academy, Trust Development
Authority, Monitor, Health Watch
England, the General Medical Council,
Nursing and Midwifery Council, NHS
Employers, Parliamentary Health
Service Ombudsman, Social Care
Institute for Excellence and NHS
Litigation Authority to embed human
factors principles and practice into the
NHS. This will include:
Developing strong leadership and understanding of human factors,
The inclusion of human factors principles and practices in educational curricula,
Alignment of the system to develop an understanding of human factors, and to create ‘Learning Organisations’ which focus on delivering high quality care,
Standardisation of clinical care, pathways and protocols.
Supporting commissioning and procurement that embeds human factors thinking.
Human factors starts from the
perspective that human error is a
natural side-effect of human
behaviour. Therefore to optimise
human performance we need to
develop a better understanding of
how healthcare professionals behave,
how individuals and teams interact
with each other and with their
environment. We also need to design
healthcare systems, processes,
pathways and devices so they take
account of human factors.
BRIEFING PURPOSE
Describe what human factors are.
Introduce the human factors in Healthcare Concordat.
Pose some questions for non-executive directors and executive directors to ask to ensure human factors is applied in their organisations.
Reflect upon potential applications of human factors in the NHS.
What are human factors?
Human factors encompass all those factors that can influence people and their behaviour.
In a work context, human factors are the environmental, organisational and job factors, and individual char-acteristics which influence behaviour at work.
(Clinical Human factors Group, 2013)
BRIEFING NOTE: 6
“During my last three years at Mid Staffordshire NHS Foundation Trust I
have become increasingly (and painfully) aware of the tragic impact of
not recognising the part played by human factors in systemic failure on
patients, families and clinical staff”
Sir Stephen Moss
Chair of the Department of Health Reference
Group on Clinical Human Factors
Understanding human factors
HUMAN FACTORS -
IMPROVING PATIENT SAFETY
Q
By acknowledging human limitations,
human factors offers ways to minimise
and mitigate human frailties, so
reducing error and its consequences.
Systems-wide adoption of human
factors principles and practices offers a
unique opportunity to support cultural
change and re-design an NHS that
improves patient safety.
There is already some excellent work
on human factors being carried out in
the NHS. Some of this work was
showcased in the “How To Guide on
Implementing Human factors in
Healthcare: Taking Further Steps
(Carthey and the Clinical Human
factors Group, 2013)”. Compared to
other high technology industries, the
NHS has only scratched the surface in
terms of applying human factors
principles and practices in healthcare.
The aviation, nuclear power
generation, oil and gas production and
rail industries routinely integrate
consideration of human factors in the
design of IT systems and devices. They
develop safety cases to anticipate risks
and to describe how they will be
mitigated.
Usability testing is used to proactively
identify design flaws with devices,
procedures and guidelines. Well-
validated tools are used to measure
the effects of workload, stress and
fatigue on human performance, and to
evaluate team non-technical skills and
culture. Incident investigations are
carried out with human factors experts
as part of the investigation team, and
apply methods that have human
factors at their core. These are just
some of the many areas where human
factors principles and practices require
development and refinement in the
NHS.
KEY QUESTIONS
Do all Board members
understand what is meant by the
term ‘human factors’?
Has your Board received a
presentation on the National
Quality Board Concordat on
Human factors in Healthcare?
Is there an executive lead for
human factors in your
organisation?
Q
Standardisation
Standardising devices, procedures and
where medications and equipment are
located reduces patient safety risks
and improves efficiency. Many patient
safety incidents could be prevented by
standardisation. For example, by
reducing the number of different
brands of infusion devices available in
a hospital.
KEY QUESTIONS
Ask the junior doctors whether
or not the location of medical
equipment and devices is
standardised across all wards?
Ask the Director of Procurement
how many different types of
infusion devices are currently in
use?
Seek out information from
healthcare teams about whether
patient safety risks are being
introduced because different
brands of the same medication
that have packaging which
could be confused with another
drug are being supplied.
BRIEFING NOTE: HUMAN FACTORS - IMPROVING PATIENT SAFETY
Let’s now consider some of the areas
where human factors principles and
practices need to be integrated in
healthcare:
Designing IT
systems and
medical devices
IT systems and medical devices should
be designed to be compatible with the
way humans process information from
the environment. Their design should
also consider the limitations with
human attention and memory,
including for example, the tendency to
see what we expect to see, especially
when working under stressful, time
pressured conditions.
When new IT systems are introduced
or new medical devices are procured,
it is important to carry out usability
testing, which involves doctors, nurses
and allied healthcare professionals
trying out the system or device by
testing it in the clinical setting in which
it will be introduced. It is also essential
that the design of IT systems and
devices is intuitive and ‘fits’ with the
clinicians expectations and how they
carry out a task.
KEY QUESTIONS
How is ‘human factors’
integrated into business
planning for investing in new or
upgrading IT systems in your
organisation?
How familiar is your Director of
IT and Director of Procurement
with the need to consider human
factors in IT systems design and
to inform decisions about what
devices and equipment to
procure?
Is usability testing carried out
before new IT systems and
medical devices are introduced?
Q
Q
Workload, stress
and fatigue
Human error is more likely to occur
when healthcare professionals are
working in conditions where the
workload is high and where they are
suffering from stress and/or are tired.
The NHS needs to apply human
factors principles and practices to
anticipate and mitigate risks caused by
excessive workload, skill mix and
stress.
KEY QUESTIONS
How is your organisation’s
winter pressures plan mitigating
workload, stress and fatigue
amongst healthcare teams?
Does the Board receive
information on numbers of
referrals to Occupational Health
caused by stress, high workload
and burnout?
Do your Board’s quality
dashboards include information
on staff turnover, absenteeism
and sickness rates per clinical
area to enable you to proactively
identify potential problem
areas?
Incident
investigation
Integration of human factors into the
incident investigation process requires
(amongst other things):
Investigation teams who have knowledge of human factors, and
Investigation teams who understand the different strengths of solutions and recommendations.
Human factors research has shown
that some of the weakest type of
safety solutions include:
writing policies and procedures,
re-training the member of staff who made an error rather than a cohort of staff who could make the same mistake,
Q
introducing another check into a process.
Effecting cultural change, simplifying
and standardising processes, re-
designing devices and designing in
forcing functions so the only way to
carry out a task is the safe way are the
strongest types of solutions.
All too often recommendations from
incident investigation reports in
healthcare rely on the weakest safety
solutions.
KEY QUESTIONS
Have the incident investigation
leads in your organisation
received training on human
factors?
Does the Board receive
assurance that
recommendations from serious
incident reports take into
consideration human factors in
developing safety solutions?
Non-technical skills
Traditionally, training in the NHS has
focused on the importance of
technical expertise. Uni-professional
training is the norm. Few healthcare
professionals receive multi-disciplinary
crew resource management training.
Crew resource management (CRM) in
healthcare is an integrated training,
process improvement and management
system that uses all available resources
including people, process and
technology to enhance safety and
operational efficiency
CRM encompasses a wide range of
knowledge, skills and attitudes, and
focuses on improving leadership,
communications, situational awareness,
problem solving, decision making, and
teamwork.
Breakdowns in non-technical skills like
leadership, situational awareness, team
work and communication are
frequently identified as contributory
factors when serious patient harm
occurs. The National Quality Board
Q
concordat details a number of case
studies which illustrate the
catastrophic consequences when non-
technical skills break down.
Non-technical skills are as important
to teamwork in Boards as they are for
teams delivering direct patient care:
For example, having a Chief Executive
who is authoritarian and not open to
constructive challenge from other
Board members will lead to safety
warnings not being heard and acted
on.
KEY QUESTIONS
What proportion of staff in your
organisation have received crew
management training to support
them to work better in multi-
disciplinary teams?
Does the organisation have a
strategy for rolling out crew
resource management training
to all relevant staff?
What is the teamwork culture
like on your Board? Are your
views listened to and acted on?
BRIEFING NOTE: HUMAN FACTORS - IMPROVING PATIENT SAFETY
Contact
Information
Key Contacts
Steve Connor
Commercial Director/Deputy
Managing Director
0151 285 4511
Our Offices
Regatta Place
Brunswick Business Park,
Summers Road Liverpool,
L3 4BL
Tel: 0151 285 4500
Fax 0151 285 4501
Salford
5th Floor Business Centre
St James’s House,
Pendleton Way, Salford,
M6 5FW
Tel: 0161 7432008
1829 Building
Countess of Chester Health Park
Liverpool Road,,
Chester,
CH2 1UL
Tel: 01244 364473
Anne-marie Harrop
Assistant Director
0151 285 4528
BRIEFING NOTE: HUMAN FACTORS - IMPROVING PATIENT SAFETY
Darwen Office
Unit 4, Arkwright Court
Commercial Road,,
Darwen, Lancashire,
BB3 0FG
Tel: 0151 285 4500
