Hf intro Mark Johnston

Quality Education for a Healthier Scotland

Multidisciplinary

Introduction to Human Factors

Mark JohnstonTraining and Research Officer

(Patient Safety)NHS Education for Scotland

[email protected] 656 3258

Workspace

Culture

Organisation

TaskTeamwork

Individual Behaviours and AbilitiesAdapted from Catchpole

@markjohnston71

mailto:[email protected]


MultidisciplinaryPre-requisite and/or reflective learning

E-learning course (for details see handout)

• Introduction to Patient Safety• Managing Human Error

Suggested reading and resources (for details see handout)


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Learning Outcomes

At the end of the session you will be able to

• Define Human Factors • Describe how factors impacting on an individual may increase

the likelihood of error• Explain the systemic factors that increase the likelihood of error

During the session you will

• Participate in discussion with delegates• Formulate an action plan for discussion with colleagues back in

your work setting


MultidisciplinaryHow safe is healthcare?

What percentage of patients entering acute care will suffer an adverse event?

NES 2013

The picture in primary care…

• 11% of prescriptions may contain a mistake• 5% of hospital admissions are caused by

medication issuesBowie, P. 2010

10%


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Why do all those avoidableharms happen?

“Just a routine operation”

https://vimeo.com/970665

https://vimeo.com/970665


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Bad people?

Error occurs due to Systemic and Systemic induced Individual failure

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

Why do all those avoidableharms happen?


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75 HF facilitators workshop Sept 11


MultidisciplinaryAn example


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You’re amazing!


MultidisciplinaryWhy do we err?

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


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Even experts err


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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!’

Reason


MultidisciplinaryWhy do we err?

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


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

PERFORMANCE

Indi

vidu

al A

uton

omy

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!)

VE

RY

UN

SA

FE

SPA

CE

IndividualPressures

PerceivedVulnerability

Belief inSystems-guidelines

Accident

Driving 100 mphillegal for all Borderline Tolerated

Conditions of Use

Adapted from Rene Amalberti


MultidisciplinaryDiscussion point

When are you more likely to make mistakes?


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Factors impacting on an individual that contribute to error

• Stress• Fatigue• Illness• Hunger/Thirst• Hazardous attitudes• Language and cultural factors


MultidisciplinaryAction plan

• Reflect on what you have heard so far• Contextualise for your workplace setting• Consider systemic problems interacting to produce

problems for the individual• Begin to complete your action plan


MultidisciplinaryBreak


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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)


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Where can we start?


(Flin, Patey 2012)

Individual Worker-Cognitive skills

• Situation awareness• Decision making

- Personal resources• Management of stress• Management of fatigue


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Cognitive skills and Situation Awareness

• Multi-tasking• Task focus


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

2 x 2=

17 x 379 =

4…System 1

6443…System 2

Now try and multi-task - do an equally difficult math problem and walk at the same time!


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Card suit change game

Groups of three

• Person A (dealer) deals cards, turning them face up in rapid succession

• Person B (subject) estimates the passing of time with no aid and counts the number of card suit changes.

• Person C (observer) times the activity using an aid and focuses on recording the suit changes

When the facilitator signals the end, B & C separately record the time and number of suit changes and then compare results.


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The amazing colour changing card trick


MultidisciplinaryExamples of individual solutions

Can you think of solutions to the problems individuals face?




problems• Continue to complete your action plan


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Where can we start?


(Flin, Patey 2012)

Workgroup/Team-Teamwork

-Team Leadership


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Characteristics of a High Performance Team

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

Borrill et al.


MultidisciplinaryTeam communication

‘The task of communication between health providers can be complicated…

an effective team is one where the team members, including the patient, communicate with one another to optimise patient care.’

WHO Multi-Professional Curriculum Guide Content Summary

‘Being an effective team player’


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So... Teams:

• Work together • Deliver services• Mutually accountable

• Another slice of cheese

• Share goals• Interdependent in their

accomplishment• Integrating is the

responsibility of all.


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Communication – a wicked problem?


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Different mental models?


MultidisciplinaryTeachback

Do you understand?

Do you have any questions?


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Initiate teach-back in a non-shaming way

• “I want to be sure I explained everything clearly. Can you explain it back to me so I can be sure I did?”

• “What will you tell your husband about the changes we made to your medicines today?”

• “We’ve gone over a lot of information. In your own words, please review with me what we talked about.”


MultidisciplinaryTeachback

http://vimeo.com/50438604




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Decode technical language

• wean PS reduce help from breathing machine

• haemofilter kidney machine

• Inotropes blood pressure medicine

• central line big drip in the neck

• ET tube breathing tube


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Be creative about how and when you use teach-back

• Focus on nodal points to optimise effectiveness– New diagnosis– Change in treatment– High risk medications– Vulnerable segments of population

• Make use of all staff groups– Nurses and AHPs– Reception staff


MultidisciplinaryHudson Bay

An example of great communication that saved lives.


MultidisciplinaryTake a moment to reflect and discuss

What stood out for you?

• Crew had never flown together before• Structured communication/calm• Errors still crept in• Checklists used• Others??


MultidisciplinarySBAR

• Situation• Background• Assessment• Recommendation.


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Yorkhill

http://www.nhsscotlandevent.com/resources/resources2013/keynote_sessions/yorkhill_safety_huddle









MultidisciplinaryLunch


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Where can we start?


Organisational/ Management

-Safety Culture-Managers’ Leadership

-Organisation communication

(Flin, Patey 2012)


MultidisciplinaryThe Scottish Approach to improving healthcare

• Safe• No avoidable injury or

harm from the healthcare they receive

• Effective

• Person Centred

• Safe• Effective• Patient

Centred• Timely• Efficient• Equal

The Institute of Medicine – 2001


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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’

culture


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Silo working?

Doctors

Managers

Nurses

What is your culture?


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Hierarchies?


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

Our learned behaviour is to blame an individual

Society

System

End point (Colleagues)?


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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


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The additive effect of Transformational Leadership

Expected Outcomes

Contingent Reward

+

Management-by-Exception

Performance beyond expectations

Transformational Leadership

Idealized Inspirational Intellectual Individualized

Influence Motivation Stimulation Consideration

Adapted from Northouse

Transactional Leadership


MultidisciplinaryLeadership

Lots of models

• Crises – Command and directive style• Tame – Managerial, standard operating procedures• Wicked – Ask questions, seek expertise from within and without

the team

Adapted from Grint 2010


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Problem Response Method

Tame Management

Process

Critical Command Answer

Wicked Leadership Question






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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’

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 who

might be stressed, fatigued and rushing.


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MultidisciplinaryActivity

Discuss in groups a problem you encounter with the work environment.

Can you think of a design solution to either the process or equipment?

Perhaps you can add it to your action plan?


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Rsaeecrh by Crmabgdie Uiisvnerty has rlveaed that so lnog as the frist and lsat lteetrs of a wrod are in the ccrroet pclae tehn the bairn wlil urdtsnaned and itpnrertae. Tihs has ilpmcotnias for stfeay


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GabAPentin

GemFIbrozil






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Where can we start?


(Flin, Patey 2012)

Workgroup/Team

Structures & processes


MultidisciplinaryDiscussion point

Under what circumstances are errors more likely to occur?


MultidisciplinarySituations when error is more likely to occur

Unfamiliarity with the task

Inexperience

Shortage of time

Inadequate checking

Poor procedures


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How do you improve the quality of care of this system?

http://www.youtube.com/watch?v=UmzDLSAEhcc

http://www.youtube.com/watch?v=UmzDLSAEhcc


MultidisciplinaryWhy does error happen?

The system may be set up to ensure we fail

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

Peter Senge


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.


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Systems thinking - The patients perspective?

• Value for the patient

• Hand-offs

• Accountability for the end-to-end experience

• Job roles

Organisational/departmental boundaries

A B C D E

Diagnostic process

Emergency care process

Treatment process


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“What matters to you?” not “What's’ the matter”


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Improved reliability of process = Improved Outcomes

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151 147 262 days Days

609+ Days

Ventilator Associated Pneumonia – Forth Valley ICU


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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 performance of the team

Sir Dave Brailsford - Performance director of British Cycling and the

general manager of Team Sky.

Improve 100 things by 1%

Don’t try to fix the whole system!






MultidisciplinaryBreak


MultidisciplinaryReview of actual incidents


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805 HF facilitators workshop Sept 11


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http://t.co/aSIEwiGD8n


http://t.co/aSIEwiGD8nhttp://t.co/aSIEwiGD8n







problems• Complete your action plan


Multidisciplinary

Introduction to Human Factors

Mark JohnstonTraining and Research Officer

(Patient Safety)NHS Education for Scotland

[email protected] 656 3258

Workspace

Culture

Organisation

Task

Teamwork

Individual Behaviours and AbilitiesAdapted from Catchpole

@markjohnston71

mailto:[email protected]

Healthcare

Hf intro Mark Johnston