Hf intro Mark Johnston

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An introduction to human factors - Mark Johnston
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 characteristics which influence behaviour at work in a way which can affect health and safety. A simple way to view human factors is to think about three aspects: the job, the individual and the organization and how they impact people’s health and safety-related behaviour

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Hf intro Mark Johnston

  1. 1. Quality Education for a Healthier Scotland Multidisciplinary Introduction to Human Factors Mark Johnston Training and Research Officer (Patient Safety) NHS Education for Scotland mark.johnston@nes.scot.nhs.uk 0131 656 3258 Workspace Culture Organisation Task Teamwork Individual Behaviours and Abilities Adapted from Catchpole @markjohnston71
  2. 2. Quality Education for a Healthier Scotland 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)
  3. 3. Quality Education for a Healthier Scotland Multidisciplinary 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
  4. 4. Quality Education for a Healthier Scotland 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 issues Bowie, P. 2010 10%
  5. 5. Quality Education for a Healthier Scotland Multidisciplinary Why do all those avoidable harms happen? “Just a routine operation” https://vimeo.com/970665
  6. 6. Quality Education for a Healthier Scotland 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 Why do all those avoidable harms happen?
  7. 7. Quality Education for a Healthier Scotland Multidisciplinary 75 HF facilitators workshop Sept 11
  8. 8. Quality Education for a Healthier Scotland MultidisciplinaryAn example 
  9. 9. Quality Education for a Healthier Scotland Multidisciplinary You’re amazing!
  10. 10. Quality Education for a Healthier Scotland MultidisciplinaryWhy do we err? • Sometimes we do the wrong thing, consciously and sub-consciously
  11. 11. Quality Education for a Healthier Scotland Multidisciplinary
  12. 12. Quality Education for a Healthier Scotland Multidisciplinary
  13. 13. Quality Education for a Healthier Scotland Multidisciplinary
  14. 14. Quality Education for a Healthier Scotland Multidisciplinary Even experts err
  15. 15. Quality Education for a Healthier Scotland Multidisciplinary 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
  16. 16. Quality Education for a Healthier Scotland MultidisciplinaryWhy do we err? • Sometimes we do the wrong thing, consciously and sub-consciously
  17. 17. Quality Education for a Healthier Scotland Multidisciplinary <1% 5% 50% 80% 100% percent of drivers PERFORMANCE IndividualAutonomy The posted speed limit is 60 mph- the ‘legal’ space Driving 64 mph -the illegal- normal space Driving 75 mph – the ‘illegal- illegal’ space (for almost all of us!) VERYUNSAFESPACE Individual Pressures Perceived Vulnerability Belief in Systems- guidelines Driving 100 mph illegal for all Borderline Tolerated Conditions of Use Adapted from Rene Amalberti
  18. 18. Quality Education for a Healthier Scotland MultidisciplinaryDiscussion point When are you more likely to make mistakes? 
  19. 19. Quality Education for a Healthier Scotland Multidisciplinary Factors impacting on an individual that contribute to error • Stress • Fatigue • Illness • Hunger/Thirst • Hazardous attitudes • Language and cultural factors 
  20. 20. Quality Education for a Healthier Scotland 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 
  21. 21. Quality Education for a Healthier Scotland MultidisciplinaryBreak
  22. 22. Quality Education for a Healthier Scotland Multidisciplinary Human Factors A 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)
  23. 23. Quality Education for a Healthier Scotland Multidisciplinary Where can we start? “Making it easy to do the right thing” (Bromiley 2011) (Flin, Patey 2012) Individual Worker -Cognitive skills •Situation awareness •Decision making - Personal resources •Management of stress •Management of fatigue
  24. 24. Quality Education for a Healthier Scotland Multidisciplinary Cognitive skills and Situation Awareness • Multi-tasking • Task focus
  25. 25. Quality Education for a Healthier Scotland Multidisciplinary 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!
  26. 26. Quality Education for a Healthier Scotland Multidisciplinary 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.
  27. 27. Quality Education for a Healthier Scotland Multidisciplinary The amazing colour changing card trick
  28. 28. Quality Education for a Healthier Scotland MultidisciplinaryExamples of individual solutions Can you think of solutions to the problems individuals face?
  29. 29. Quality Education for a Healthier Scotland MultidisciplinaryAction plan • Reflect on what you have heard so far • Contextualise for your workplace setting • Consider systemic problems interacting to produce problems • Continue to complete your action plan 
  30. 30. Quality Education for a Healthier Scotland Multidisciplinary Where can we start? “Making it easy to do the right thing” (Bromiley 2011) (Flin, Patey 2012) Workgroup/Team -Teamwork -Team Leadership
  31. 31. Quality Education for a Healthier Scotland Multidisciplinary Characteristics of a High Performance Team 1. Clear Objectives 2. Encouragement of Participation 3. Emphasis on Quality 4. Support for Innovation 5. Communication Borrill et al.
  32. 32. Quality Education for a Healthier Scotland 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’
  33. 33. Quality Education for a Healthier Scotland Multidisciplinary So... Teams: • Work together • Deliver services • Mutually accountable • Another slice of cheese • Share goals • Interdependent in their accomplishment • Integrating is the responsibility of all.
  34. 34. Quality Education for a Healthier Scotland Multidisciplinary Communication – a wicked problem?
  35. 35. Quality Education for a Healthier Scotland Multidisciplinary Different mental models?
  36. 36. Quality Education for a Healthier Scotland Multidisciplinary Teachback Do you understand? Do you have any questions?
  37. 37. Quality Education for a Healthier Scotland Multidisciplinary 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.”
  38. 38. Quality Education for a Healthier Scotland Multidisciplinary Teachback http://vimeo.com/50438604
  39. 39. Quality Education for a Healthier Scotland Multidisciplinary 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
  40. 40. Quality Education for a Healthier Scotland Multidisciplinary 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
  41. 41. Quality Education for a Healthier Scotland Multidisciplinary Hudson Bay An example of great communication that saved lives. 
  42. 42. Quality Education for a Healthier Scotland Multidisciplinary Take 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?? 
  43. 43. Quality Education for a Healthier Scotland MultidisciplinarySBAR • Situation • Background • Assessment • Recommendation.
  44. 44. Quality Education for a Healthier Scotland Multidisciplinary Yorkhill http://www.nhsscotlandevent.com/resources/resources2013/ keynote_sessions/yorkhill_safety_huddle
  45. 45. Quality Education for a Healthier Scotland MultidisciplinaryAction plan • Reflect on what you have heard so far • Contextualise for your workplace setting • Consider systemic problems interacting to produce problems • Continue to complete your action plan 
  46. 46. Quality Education for a Healthier Scotland MultidisciplinaryLunch
  47. 47. Quality Education for a Healthier Scotland Multidisciplinary Where can we start? “Making it easy to do the right thing” (Bromiley 2011) Organisational/ Management -Safety Culture -Managers’ Leadership -Organisation communication (Flin, Patey 2012)
  48. 48. Quality Education for a Healthier Scotland 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
  49. 49. Quality Education for a Healthier Scotland Multidisciplinary ‘We cannot change the condition of those who do the work, but we can change the conditions within which they work’ culture
  50. 50. Quality Education for a Healthier Scotland Multidisciplinary Silo working? Doctors Managers Nurses What is your culture?
  51. 51. Quality Education for a Healthier Scotland Multidisciplinary Hierarchies?
  52. 52. Quality Education for a Healthier Scotland Multidisciplinary 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)?
  53. 53. Quality Education for a Healthier Scotland Multidisciplinary Lessons for Leadership in changing culture Culture change and continual improvement come from what leaders do, through their commitment, encouragement, compassion and modelling of appropriate behaviours. Berwick Report 2013
  54. 54. Quality Education for a Healthier Scotland Multidisciplinary 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
  55. 55. Quality Education for a Healthier Scotland 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
  56. 56. Quality Education for a Healthier Scotland Multidisciplinary Problem Response Method Tame Management Process Critical Command Answer Wicked Leadership Question
  57. 57. Quality Education for a Healthier Scotland MultidisciplinaryAction plan • Reflect on what you have heard so far • Contextualise for your workplace setting • Consider systemic problems interacting to produce problems • Continue to complete your action plan 
  58. 58. Quality Education for a Healthier Scotland Multidisciplinary Where can we start? “Making it easy to do the right thing” (Bromiley 2011) (Flin, Patey 2012) Work/Environment -Work environment and hazards (ergonomics)
  59. 59. Quality Education for a Healthier Scotland 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.
  60. 60. Quality Education for a Healthier Scotland 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.
  61. 61. Quality Education for a Healthier Scotland Multidisciplinary
  62. 62. Quality Education for a Healthier Scotland 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? 
  63. 63. Quality Education for a Healthier Scotland Multidisciplinary 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
  64. 64. Quality Education for a Healthier Scotland Multidisciplinary GabAPentin GemFIbrozil
  65. 65. Quality Education for a Healthier Scotland MultidisciplinaryAction plan • Reflect on what you have heard so far • Contextualise for your workplace setting • Consider systemic problems interacting to produce problems • Continue to complete your action plan 
  66. 66. Quality Education for a Healthier Scotland Multidisciplinary Where can we start? “Making it easy to do the right thing” (Bromiley 2011) (Flin, Patey 2012) Workgroup/Team Structures & processes
  67. 67. Quality Education for a Healthier Scotland MultidisciplinaryDiscussion point Under what circumstances are errors more likely to occur? 
  68. 68. Quality Education for a Healthier Scotland MultidisciplinarySituations when error is more likely to occur Unfamiliarity with the task Inexperience Shortage of time Inadequate checking Poor procedures 
  69. 69. Quality Education for a Healthier Scotland Multidisciplinary How do you improve the quality of care of this system? http://www.youtube.com/watch?v=UmzDLSAEhcc
  70. 70. Quality Education for a Healthier Scotland 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
  71. 71. Quality Education for a Healthier Scotland 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.
  72. 72. Quality Education for a Healthier Scotland Multidisciplinary
  73. 73. Quality Education for a Healthier Scotland Multidisciplinary 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
  74. 74. Quality Education for a Healthier Scotland Multidisciplinary “What matters to you?” not “What's’ the matter”
  75. 75. Quality Education for a Healthier Scotland Multidisciplinary Improved reliability of process = Improved Outcomes 0 1 2 3 4 5 6 7 8 Oct-06 Feb-07 Jun-07 Oct-07 Feb-08 Jun-08 Oct-08 Feb-09 Jun-09 Oct-09 Feb-10 Jun-10 Oct-10 Feb-11 Jun-11 Oct-11 Feb-12 VAPIncidence(outcomemeasure) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% BundleReliability(processmeasure) 151 147 262 days Days 609+ Days Ventilator Associated Pneumonia – Forth Valley ICU
  76. 76. Quality Education for a Healthier Scotland Multidisciplinary 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!
  77. 77. Quality Education for a Healthier Scotland MultidisciplinaryAction plan • Reflect on what you have heard so far • Contextualise for your workplace setting • Consider systemic problems interacting to produce problems • Continue to complete your action plan 
  78. 78. Quality Education for a Healthier Scotland MultidisciplinaryBreak
  79. 79. Quality Education for a Healthier Scotland MultidisciplinaryReview of actual incidents
  80. 80. Quality Education for a Healthier Scotland Multidisciplinary 805 HF facilitators workshop Sept 11
  81. 81. Quality Education for a Healthier Scotland Multidisciplinary http://t.co/aSIEwiGD8n
  82. 82. Quality Education for a Healthier Scotland MultidisciplinaryAction plan • Reflect on what you have heard so far • Contextualise for your workplace setting • Consider systemic problems interacting to produce problems • Complete your action plan 
  83. 83. Quality Education for a Healthier Scotland Multidisciplinary Introduction to Human Factors Mark Johnston Training and Research Officer (Patient Safety) NHS Education for Scotland mark.johnston@nes.scot.nhs.uk 0131 656 3258 Workspace Culture Organisation Task Teamwork Individual Behaviours and Abilities Adapted from Catchpole @markjohnston71

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