Mark Johnston driver diagrams

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

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 issues
Bowie, P. 2010
10%

Multidisciplinary
Why do all those avoidable
harms happen?
“Just a routine operation”
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 avoidable
harms happen?

Multidisciplinary
75 HF facilitators workshop Sept 11

MultidisciplinaryAn example


Multidisciplinary
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

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<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

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 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)

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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!

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.

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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 Objectives
2. Encouragement of Participation
3. Emphasis on Quality
4. Support for Innovation
5. 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?

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Teachback
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.”

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Teachback
http://vimeo.com/50438604

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

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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

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Hudson Bay
An example of great
communication that saved lives.


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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??


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 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

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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.

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?


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

Multidisciplinary
GabAPentin
GemFIbrozil

Multidisciplinary
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


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

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

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

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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

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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!

MultidisciplinaryReview of actual incidents

Multidisciplinary
805 HF facilitators workshop Sept 11

Multidisciplinary
http://t.co/aSIEwiGD8n

problems
• Complete your action plan


Mark Johnston driver diagrams

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