introduction to human factors - nes...aggregation of marginal gains • small improvements in a...
TRANSCRIPT
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Multidisciplinary
Introduction to Human Factors
Mark JohnstonTraining and Research Officer
(Patient Safety)
Workspace Culture
Task Teamwork
Quality Education for a Healthier Scotland
(Patient Safety)NHS Education for Scotland
[email protected] 656 3258
Organisation
Behaviours and AbilitiesAdapted from Catchpole
@markjohnston71
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MultidisciplinaryWhy do we make mistakes?
The system may be set up to fail
‘every system is perfectly designed to achieve the
Quality Education for a Healthier Scotland
‘every system is perfectly designed to achieve the results it gets’
Peter Senge.
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Multidisciplinary
Quality Education for a Healthier Scotland
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Multidisciplinary
Quality Education for a Healthier Scotland
45 HF facilitators workshop Sept 11
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MultidisciplinaryYour amazing!
Quality Education for a Healthier Scotland
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MultidisciplinaryWhy do we make mistakes?
• Sometimes we do the wrong thing, consciously and
Quality Education for a Healthier Scotland
• Sometimes we do the wrong thing, consciously and sub-consciously
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Multidisciplinary
Indi
vidu
al A
uton
omy
Driving 64 mph-the illegal-
Driving75 mph –the ‘illegal-illegal’space (for almost all
VE
RY
UN
SA
FE
SP
AC
EIndividualPressures
PerceivedVulnerability
Driving 100 mph
illegal for all Borderline Tolerated
Conditions of Use
Quality Education for a Healthier Scotland
<1% 5% 50% 80% 100% percent of drivers
PERFORMANCE
The posted speed limit is 60 mph- the ‘legal’ space
-the illegal-normal space
almost all of us!)
VE
RY
UN
SA
FE
SP
AC
E
Vulnerability
Belief inSystems-guidelines
Adapted from Rene Amalberti
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Multidisciplinary
Human FactorsA common language
“Enhancing clinical performance through an understanding of theeffects of teamwork, tasks, equipment, workspace, culture andorganisation on human behaviour and abilities and application ofthat knowledge in clinical settings” (Catchpole 2010)
Quality Education for a Healthier Scotland
“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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Multidisciplinary
Quality Education for a Healthier Scotland
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Multidisciplinary
Quality Education for a Healthier Scotland
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Multidisciplinary
Quality Education for a Healthier Scotland
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Multidisciplinary
Even experts make mistakes
Quality Education for a Healthier Scotland
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Multidisciplinary
Two examples of our brains making errors
• Multi-tasking• Task focus
Quality Education for a Healthier Scotland
• Task focus
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Multidisciplinary
Multi-tasking - Our lazy brains would rather default to system 1
2 x 2 = 4…System 1
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17 x 379 = 6443…System 2.
Now try and multi-task - do an equally difficult math problem and walk
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MultidisciplinaryThe amazing colour changing card trick
Quality Education for a Healthier Scotland
http://www.youtube.com/watch?annotation_id=annotation_262395&feature=iv&src_vid=voAntzB7EwE&v=v3iPrBrGSJM
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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!’
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a brain!’Reason
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Multidisciplinary
Where can we start?
“Making it easy to do the right thing” (Bromiley 2011)
Quality Education for a Healthier Scotland
(Flin, Patey 2012)
Work/Environment-Work environment
and hazards(ergonomics)
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Multidisciplinary
‘We cannot change the condition of those who do the work, but we can change the conditions within which they work’
Quality Education for a Healthier Scotland
the conditions within which they work’
Reason J. BMJ. 2000 March 18; 320(7237): 768–770.
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MultidisciplinaryEveryone, everywhere, every time
Good human factors design in health care accommodates everyone
Quality Education for a Healthier Scotland
Not just the calm, rested experienced healthcare worker
But also the inexperienced health-care worker whomight be stressed, fatigued and rushing.
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Multidisciplinary
Quality Education for a Healthier Scotland
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Multidisciplinary
Where can we start?
“Making it easy to do the right thing” (Bromiley 2011)
Quality Education for a Healthier Scotland
Organisational/ Management-Safety Culture
-Managers’ Leadership-Organisation communication
(Flin, Patey 2012)
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Multidisciplinary
‘We cannot change the condition of those who do the work, but we can change the culture within which they work’
Quality Education for a Healthier Scotland
the culture within which they work’
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Multidisciplinary
Admin
Nurses
What is your culture?
Quality Education for a Healthier ScotlandSilo working?
Dentists
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Multidisciplinary
Quality Education for a Healthier Scotland
Hierarchies?
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Multidisciplinary
Do we pay attention to the Swiss cheese or do we blame?
Our learned behaviour is to blame an individual
Society
Quality Education for a Healthier Scotland
System
End point (Dental Colleagues)?
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Multidisciplinary
Where can we start?
“Making it easy to do the right thing” (Bromiley 2011)
Quality Education for a Healthier Scotland
(Flin, Patey 2012)
Workgroup/Team-Teamwork
-Team Leadership
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Multidisciplinary
Lessons for Leadership inchanging culture
Culture change and continual improvement come fromwhat leaders do, through
Quality Education for a Healthier Scotland
what leaders do, through their commitment, encouragement, compassion and modelling of appropriate behaviours.
Berwick Report 2013
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MultidisciplinaryTeam communication and culture
‘The task of communication between health providerscan be complicated… an effective team is one wherethe team members, including the patient,
Quality Education for a Healthier Scotland
the team members, including the patient,communicate with one another to optimise patientcare.’
WHO Multi-Professional Curriculum Guide Content Summary
‘Being an effective team player’
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Multidisciplinary
Different mental models?
Jaap video
Quality Education for a Healthier Scotland
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MultidisciplinaryHudson Bay
An example of great communication that saved lives.
Quality Education for a Healthier Scotland
communication that saved lives.
http://www.youtube.com/watch?v=_QazS0uo-eg
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MultidisciplinaryTake a moment to reflect and discuss
What stood out for you?
• Crew had never flown together before• Structured communication/calm
Quality Education for a Healthier Scotland
• Structured communication/calm• Checklists used• Errors still crept in• Others??
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Multidisciplinary
So... Teams:
• Work together
• Deliver services
• Mutually accountable
• Share goals
Quality Education for a Healthier Scotland
• Share goals
• Interdependent in their accomplishment
• Integrating is the responsibility of all.
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Multidisciplinary
Characteristics of a High Performance Team
1. Clear Objectives2. Encouragement of Participation3. Emphasis on Quality4. Support for Innovation5. Communication
Quality Education for a Healthier Scotland
5. CommunicationBorrill et al
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MultidisciplinarySBAR
• Situation• Background
Quality Education for a Healthier Scotland
• Assessment• Recommendation.
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Multidisciplinary
Where can we start?
“Making it easy to do the right thing” (Bromiley 2011)
Quality Education for a Healthier Scotland
(Flin, Patey 2012)
Workgroup/Team
Structures & processes
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MultidisciplinaryExamples in healthcare…
• Prescribing and dispensing
• Hand-over/hand-off information
• If all of the processes associated with these
Quality Education for a Healthier Scotland
information
• Movement of patients
• Ordering of tests
• Preparation of medication
associated with these tasks make sense and become easier for the ‘human’ to comply with, then patient safety will improve.
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Multidisciplinary
Quality Education for a Healthier Scotland
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Multidisciplinary
Systems thinking - The patients perspective?
•Value for the patient
•Hand-offs
Organisational/departmental boundaries
A B C D E
Emergency care process
Quality Education for a Healthier Scotland
•Accountability for the end-to-end experience
•Job roles
Diagnostic process
Emergency care process
Treatment process
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Multidisciplinary
Improved reliability of process = Improved Outcomes
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Ventilator Associated Pneumonia – Forth Valley ICU
Quality Education for a Healthier Scotland
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151 147 262
609+ Days
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Multidisciplinary
Change is a wicked problem!
OK, I’m ready for a change now…any time would be
fine!
Quality Education for a Healthier Scotland
“Nobody really looks forward to change, except a wet baby!”
Participant in a QI Workshop, 2006
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Multidisciplinary
A model for learning and changeA mechanism to generate questions
Lots of questions to help frame the problem and generate ideas
Quality Education for a Healthier Scotland
Test our idea on a small scale to learn as we go
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Multidisciplinary
The PDSA Cycle for Learning and Improvement
What changes are tobe made for the
PlanActObjective, questions and predictions (why)Plan to carry out the cycle (who,
Quality Education for a Healthier Scotland
be made for thenext cycle?
Carry out the planDocument problemsand unexpectedobservationsBegin analysis of the data
Complete the
analysis of the dataCompare data to
predictionsSummarise what
was learned
DoStudy
the cycle (who, what, where, when)
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Multidisciplinary
PDSA example: Christopher
Christopher to urinate into the
Aim:
Quality Education for a Healthier Scotland
urinate into the toilet bowl 100% of the time by 30th June 2010.
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Multidisciplinary
PDSA template
Describe your first (or next) test of change:
Person responsible
When to be done
Where tobe done
Demonstrate the correct way to urinate into the bowl and indicate the negative aspects of missing the bowl
Me tonight Downstairs toilet
Quality Education for a Healthier Scotland
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List the tasks needed to set up this test of change
Person responsible
When to be done
Where to be done
Christopher available Me tonight Downstairs WC
Predict what will happen when the test is carried out
What will determine if prediction succeeds
Christopher will show understanding of process and execute correctly
The floor will be dry
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Multidisciplinary
Example: DSADo
Christopher thought the demonstration amusing and ignored it
Study
0% compliance with the new process
Quality Education for a Healthier Scotland
0% compliance with the new process
0% reliability level
Act
Seek out ideas, develop new test cycle.
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Multidisciplinary
Example: next PDSA cycle
Quality Education for a Healthier Scotland
http://www.amazon.co.uk/toilet-training-target-stickers-Happeedays/dp/B002GZAWUK/ref=pd_sim_by_3
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Multidisciplinary
The value of ‘failed’ tests
“I did not fail one thousand times; I found one thousand ways how
Quality Education for a Healthier Scotland
one thousand ways how not to make a light bulb.”
Thomas Edison
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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
Don’t try to fix the whole system!
Quality Education for a Healthier Scotland
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%
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Multidisciplinary
He is a real dentist!
Quality Education for a Healthier Scotland
Thanks for listening!
@markjohnston71