9/29/2014 Systems Engineering Initiative SEIPS For Patient Safety - - PDF document

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9/29/2014 Systems Engineering Initiative SEIPS For Patient Safety - - PDF document

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9/29/2014 Systems Engineering Initiative SEIPS For Patient Safety APIC Palmetto Fall Educational Conference 2014 Understand the System Large scale issues in sociotechnical systems Human Factors 101 In Quality and IP we were

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Human Factors 101

Carla J. Alvarado, PhD

Research Scientist Emerita University of Wisconsin-Madison Phone: 608.695.8746 Email: calvarado@cqpi.engr.wisc.edu 23 October 2014

APIC-Palmetto Fall Educational Conference 2014

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Understand the “System”

Large scale issues in sociotechnical systems In Quality and IP we were trained to break down into parts…but in complex systems – Relationships between parts are far greater than the parts alone… Resilience…resilience aligns with what is described as a ‘‘new view of human error’’ which sees humans in a system as a primary source of resilience in creating

  • safety. The ‘‘old view’’ focuses more on the elimination
  • f risk rather than, more realistically describing

strategy that will circumscribe, cope and contain failure, as proposed by resilience

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Example

Termite hill

  • Can’t be reduced to the termites
  • Statistically emergent from termite
  • By the way there is no CEO termite or CNO-VP

patient services termite etc., just termites that all know their places and tasks in the system THE TERMITES HAVE A SHARED MENTAL MODEL We establish order and control through actions of a few top people in the organization – this may be the biggest factor holding back innovation and progress in our

  • rganizations

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In a Complex System Relationships between parts are far greater than the parts alone…

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So what do we do? The prevailing healthcare prevention system paradigm:

Slide stolen from Matt Scanlon, MD

“Whac-a-Mole” explained

  • Try to predict where problem will be based
  • n past experience
  • Identify individuals involved
  • Determine they are at fault
  • Retrain them or even

punish them

  • Failure? Do the same analysis all over

again…

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“Whac-a-Mole” is an Anticipatory Model

This is an anticipatory model – based on prediction

  • f problems occurring again…in the exact same

way! You guess or try to “pattern match” (data) where the “mole will pop up” But…what is the problem with this model

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Problems with the anticipatory model

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Complex Systems – agents actions are based on internalized rules

Instincts, constructs and mental models Internal rules may not be shared, explicit or even logical i.e. the doctor, the nurse, the housekeeper – all have different internalized rules Is there a “shared mental model” for hand hygiene or is it individual, internalized rules?

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Person Approach vs. Systems Approach

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and latent conditions…the “resident pathogens within the system”

Latent failures occur when individuals make decisions that have unintended consequences in the future.

i.e. staffing models that depend on providers to routinely perform clinical duties above and beyond their responsibilities – introducing time pressures, fatigue, low moral

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What makes healthcare a unique complex system, unlike aviation or chemical plant?

  • Bad outcomes affect one person and the

family versus bad outcomes can kill hundreds (aviation) or thousands (chemical or nuclear power)

  • Therefore the regulatory environments

and public perceptions (external environment) are different

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  • As quickly and accurately as you can –

Raise your hand and close your eyes when you know HOW MANY results are

  • ut of range.

Ready….THEN KEEP YOUR EYES CLOSED UNTIL I SAY “OPEN”

Can HFE Help?

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What was the difference?

  • The first data presentation was cognitively challenging because

you needed to mentally find the lab value, and then interpret whether or not the value was in range.

  • Each comparison was an opportunity for error.
  • The second provided what we call a direct perception display to

answer the cognitive challenge I posed to you.

  • Both are typical of types of displays you might encounter every
  • day. Both affected accuracy (quality/safety) and response time

(productivity).

What was the patient?

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Overload  Underload

Task demands too high, performance deteriorates because of limited resources Task demands too low, performance deteriorates because of boredom and distractibility

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*Slides compliments of Lauri Wolf and Brad Evanoff, BJC, St. Louis MO

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After

*Slides compliments of Lauri Wolf and Brad Evanoff, BJC, St. Louis MO

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Person

Capabilities and Limitations

  • Musculo/skeletal
  • Sensory
  • Cognitive
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Physical Environment

  • Sensory disruptions: make it difficult to carry
  • ut tasks
  • Air quality: too hot, too cold, smells, stuffy
  • Noise: can increase
  • blood pressure,
  • negative mood
  • Housekeeping
  • Fatigue, stress

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Tasks

(studied more than any element of the model)

  • Content considerations-repetitiveness and

meaningfulness

  • Lack of participation and control
  • Skill/knowledge required
  • Overload and underload
  • Paced work

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Technology/Tools/Training

  • Controls, displays - Cognitive skills
  • Computers
  • New technologies
  • Bar coding; RFID
  • Device design
  • eMAR
  • Hand Hygiene Products

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Technology Design

  • Adding technology may be like adding

another team member, but one who does not speak the same language or share the same cultural assumptions. (Woods 1996)

  • That may lead to “technology surprises” -

What is the technology doing now? Why is it doing that? What will it do next?

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Organization - Local

  • Training, new technology, time for acclimation, work

schedules

  • Pay and benefits - Motivation?
  • Management and supervision
  • Employee identification
  • Corporate structure
  • Corporate culture
  • Organizational support
  • Job growth

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Organization - Global

  • Federal laws, national guidelines,

standards

  • International guidelines, standards
  • Accrediting organizations
  • Professional organizations
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Discussion of System Models

  • All of the elements interact with each other and

any change in one element (e.g. change in lighting, work flow, technology) will affect the

  • ther elements.
  • If all of the elements are not designed to fit

together, there is a misfit.

  • A misfit can lead to productivity, efficiency,

safety and quality problems.

  • Latent errors or problems down the line

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How will we use HFE?

  • Observational Task Analysis of lower level

providers based on the elements of the HFE work system model

  • Look for Barriers and Enablers to hand hygiene and

the Five Moments

  • Surveys of users
  • Focus groups of users
  • Do your colleagues share

the same Mental Model?

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Let’s Return to the Good Samaritan and the NYC Burn Nurse

Nurses always performed hand hygiene after removing gloves but not very compliant before donning gloves…why? Wet hands do not go into gloves. Hands were wet with ABHR took TIME to dry and they wanted to get on to the “task” Products placed in inconvenient locations took TIME to find Workflow patterns made sink and product locations different for RNs vs. MDs “Counting” was everywhere but how do we use it? How about for good location of products?

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How Can I Help Identify the Hand Care Agents?

Use color … but only in combination with other identification such as prominent lettering, dispenser shape, sound etc. Color is ALWAYS a secondary identifier. Extra Credit: Anyone have trouble seeing the “C” and/or the “r”? Why?

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How Can I Help Identify Locations for Agents?

  • Consider placement visibility, flexibility, accessibility

and consistency…and if alcohol based fire safety

  • Digital actuation counters on products…not for hand

hygiene data but rather location use

  • Post-It Notes color designated to soap, alcohol based

hand rub (ABHR) and lotion. All employees have them and place them on a surface where a hand hygiene opportunity occurred but sink/agent was not easily accessible

  • Patient rooms available for dynamic placement of

agents based on user feedback

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Patient rooms available for dynamic placement of agents based on user feedback

Post-It Notes or stickers color designated to soap, alcohol based hand rub and lotion. All employees have them and place them on a surface where a hand hygiene

  • pportunity occurred but sink/agent was not easily

accessible

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What Can “We” Do?

Vernon MO, Hayden MK, Trick WE, Hayes RA, Blom DW, Weinstein RA. Chlorhexine gluconate to cleanse patients in a medical intensive care unit. Arch Intern Med. 2006;166:306-312.

  • Single intervention (2% CHG disposable cloths) targeting

source control lowered new acquisition of multi-resistant

  • rganisms (MRO), reduced MRO in environment and on

healthcare workers hands

  • The CHG was to reduce MRO on the patient but it

becomes a “passive” healthcare hand and environmental hygiene agent – “chunking”

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Remember Semmelweis? What is the model for the cause of puerperal fever?

Person Task Tools/Technology Environment

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Human Factors Task Analysis

Societal/Organization factors - infected patients’ socioeconomic class causes placement in hospital vs. their home Physical Environment factors - water quality, patient bed linens, ventilation, and patient crowding Task factors - difficult or extended labors requiring more physician/medical student attention than normal deliveries left to the midwives Tools and Technology in use – comparing hospital and at home deliveries People – physician, medical student, midwife, patients.

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Organization

The cause was one of advancement in medical technology –

  • years prior, incidence of puerperal fever had

been equally low in both wings of the hospital

  • emergence of forensic pathology-the opening of

the new Institute of Anatomy, instructional autopsies came into academic fashion and were required of all physicians with patients that died in the hospital

  • His analysis clearly describes a latent error in the

system, placing the medical staff at the “sharp” of the infection transmission or medical error

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Human factors design interventions have been suggested to mitigate infection risk in health care. Among such solutions, many are easily identified and theoretically simple and quick to realize. These are called low-hanging fruit. We present a case of infection risk associated with syringe manipulation that could easily be solved by introducing user-centered design

  • solutions. Yet, organizational complexity makes

implementation of such solutions hardly reachable. We therefore advocate embedding human factors macroergonomic expertise on an organizational level.. Low-hanging fruit for human factors design in infection prevention—still too high to reach?

Lauren Clack, BSc, Stefan P. Kuster, MD, MSc, Heidi Giger, RN, Francesca Giuliani, PhD and Hugo Sax, MD

American Journal of Infection Control Volume 42, Issue 6, Pages 679-681 (June 2014)

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“Le mieux est l'ennemi du bien.”

  • Voltaire 1772

We cannot, however, let the perfect be the enemy of the good.

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Thank you for your expertise, dedication, and your time this morning with me…

Carla J. Alvarado, PhD Research Scientist Emerita University of Wisconsin – Madison 3100 Lake Mendota Drive Madison, WI 53705 calvarado@cqpi.engr.wisc.edu Phone: 608/695‐8746