HF_CEO_Present

An Introduction to Human Factors –Design for Use by Humans : 

An Introduction to Human Factors –Design for Use by Humans Marc Bennett, CEO, HealthInsight With credits to: Michelle Geis & Michael P. Silver AHQA CEO Meeting, April 2003

Overview and Summary : 

Overview and Summary Introduction to human factors and safety management Principles applied to 6th SOW inpatient clinical topic areas Application and implementation in SOW7 Conclusions & Implications

Slide 3: 

Human factors is: The science of designing tools, tasks, information, and work systems to be compatible with the abilities of human users; this includes both physical and cognitive abilities. (This discussion considers also risk perception and behavioral propensities.)

Slide 4: 

Error (from Reason, 1990): Error … those occasions in which a planned sequence of mental or physical activities fails to achieve its intended outcome and the failure can’t be attributed to the intervention of some chance agency. Errors can be further divided into errors of execution (slips, lapses) and errors of planning (mistakes).

A Design Example:Structural Steel : 

Bending Crushing Deflection Thermal Effects A Design Example:Structural Steel

Information Processing and Response : 

Information Processing and Response Perception Response Execution Long-Term Memory Working Memory Decision and Response Selection Attention Resources Memory Feedback Stimuli Response

Attention : 

Attention Perception Response Execution Long-Term Memory Working Memory Decision and Response Selection Attention Resources Memory Feedback Stimuli Response

Error and Cognitive Performance : 

Error and Cognitive Performance Perception Response Execution Long-Term Memory Working Memory Decision and Response Selection Attention Resources Memory Feedback Stimuli Response

Situated Cognition and Context : 

Situated Cognition and Context Perception Response Execution Long-Term Memory Working Memory Decision and Response Selection Attention Resources Memory Feedback Stimuli Response

Cognition & Performance : 

Cognition & Performance

Error Types : 

Error Types

Performance Levels and Exposure : 

Performance Levels and Exposure exposure performance level Skill- based Rules- based Knowledge- based

Performance Levels and Likelihood of Error : 

Performance Levels and Likelihood of Error exposure performance level Skill- based Rules- based Knowledge- based likelihood of error

Generic Tasks and Error Probabilities : 

Generic Tasks and Error Probabilities

Slide 15: 

Behavioral Psychology and Safety Management Violations – intentional deviations from safe operating procedures, standards, or rules.

Violation Producing Conditions : 

Violation Producing Conditions

Human Factors and the Nolan Model for Improvement : 

Human Factors and the Nolan Model for Improvement Plan Study Do Act What are we trying to accomplish? How do we know that a change is an improvement? What changes can we make that result in an improvement? Human factors can help answer this question!

Human Factors as a Design Discipline : 

Human Factors as a Design Discipline Performance is a product of design – error is a consequence Change stimuli/task information characteristics Team work Reminders/prompts Impact attention (carefully) Change contents of long-term memory Redistribute tasks Provide feedback/make the state of the system visible Reduce reliance on short-term memory and vigilance Manage performance-shaping factors Engineer limiting (or forcing) functions

Human Factors as a Diagnosis Tool : 

Human Factors as a Diagnosis Tool Improving a work system starts with diagnosis – why isn’t it working? Task analysis: Information characteristics, Complexity, Time constraints Context Operator: Goals, Mindset, Information available Team functioning . . . .

Slide 20: 

What causes conditions that promote errors and violations? Gap Information Management Unfamiliar Task Goal Conflicts Perceived Authority to Violate Rule Measure Violations Errors Poor Task Design ?

Slide 21: 

Safety Culture & Organizational Factors Gap Information Management Unfamiliar Task Perceived Authority to Violate Rule Measure Poor Task Design Errors Violations Goal Conflicts Leadership orientation and effectiveness Assumptions about human performance capacity Operational models of error causation Safety/performance information systems Assumptions about the roles of organizations, professionals, regulation, and accreditation Promotion of effective team development and functioning Organizational values Tolerance of deviation or rule violations Organizational Factors/ Safety Culture Error/violation promoting conditions Examples of potentially important organizational dimensions (not a comprehensive list).

What’s the alternative? : 

What’s the alternative? Health care quality improvement without human factors Resistance to change? Do reminders work? Will time-series analysis help our customers achieve their aims? Is education an effective system change? Does academic detailing work? Are incentives effective? Are “systems changes”effective? We have to do better than observe that there is no magic bullet. Human factors makes the performance of the system more comprehensible and helps us ask better questions.

Changing the World : 

Changing the World (Re)Design the person? Perception Decision and response execution Working memory Long-term memory Response execution Attention (Re)Design the world? Stimuli Effects of response Distribution of tasks

Human Factors at HealthInsight : 

Human Factors at HealthInsight 1997: Reducing Medication Errors in Utah Recognized need for study of error management 1997 ??? human factors psychology safety management aviation safety organizational risk management human factors (or ergonomics) is designing for human use

Applications to HCQIP? : 

Applications to HCQIP? ’97-’98: expected result ’99-’??: surprises! 1997 human factors psychology safety management aviation safety organizational risk management 1999 6th SOW Inpatient? HF Stroke AMI Pneumonia 2001 Internal HealthInsight processes?

How was this different? : 

How was this different? human factors psychology safety management aviation safety organizational risk management 1999 6th SOW Inpatient It made us curious about different things! information management information availability data overload situational complexity teamwork communication expertise competing goals norms and culture complexity task design mindset

This produced fundamental changes in the content of our interactions with hospitals : 

This produced fundamental changes in the content of our interactions with hospitals We re-evaluated our assumptions about: Causes of performance gaps What information is useful for health care quality improvement Identifying appropriate systems change strategies

Application and Implementation : 

Application and Implementation Multifaceted intervention Facilitated systems review exercises (Taking Stock) Team approach – pharmacy, nursing participation Sharing sessions (not Breakthrough) Performance data feedback Guideline/educational materials

Intervention Activities : 

Intervention Activities Hospital Liaisons – Taking Stock Series of (approx) 3 meetings per hospital per year Sharing Sessions 4 sessions – focused on clinical areas sharing interventions, successes and barriers Data – Interim Measures Created hospital specific data sheets w/baseline, two interim measure periods, final

Results – 6th SOW Evaluation : 

Results – 6th SOW Evaluation 15 of 16 quality indicators improved Topic weighted average improvement AMI 32.2% RI Heart Failure 24.3% RI Stroke 18.7% RI Pneumonia 33.9% RI Of the 17 largest hospitals in the state 5 (29%) with RI greater than 45% 6 (35%) with RI between 25% and 39%

6th SOW Performance, by State : 

6th SOW Performance, by State

Limitations of 6SOW Analysis : 

Limitations of 6SOW Analysis Cannot isolate HealthInsight impact from larger trends operating statewide Cannot disaggregate contributions of different facets of intervention strategy Implementation was dependent on prior relationships and history with hospitals

7th SOW Strategy : 

7th SOW Strategy Integrated Human Factors Collaborative Series Across all Four Settings Training a cadre of process (re)designers Human factors “change packages” Organizing structure Site-specific learning “Communities of Practice” Community partnerships Supportive interventions: e.g.; OBQI training, public data release, SIP & diabetes breakthrough collaboratives, etc.

“Human error in medicine, and the adverse events that may follow, are problems of psychology and engineering, not of medicine.”J.W. Senders : 

“Human error in medicine, and the adverse events that may follow, are problems of psychology and engineering, not of medicine.”J.W. Senders

Conclusions : 

Conclusions We must accelerate pace of change Health care delivery is more complex than some models for improvement Human factors & safety management disciplines help address this challenge Human Factors application requires investment in learning

Suggested Reading : 

Suggested Reading Reason J. Managing the Risks of Organizational Accidents. Brookfield, VT: Ashgate, 1997. Norman DA. Design of Everyday Things. New York: Doubleday, 1988. Norman DA. Things that make us smart. Reading, MA: Addison-Wesley, 1993. Reason J. Human Error. New York: Cambridge University Press, 1990. Helmreich RL & Merritt AC. Culture at Work in Aviation and Medicine. Brookfield, VT: Ashgate, 1998. Klein G. Sources of Power: How People Make Decisions. Cambridge, MA: The MIT Press, 1999. Kaneman D, Slovic P, & Tversky A (Eds.). Judgement Under Uncertainty: Heuristics and Biases. New York: Cambridge University Press, 1982. Rasmussen J, Pejtersen AM, & Goodstein LP. Cognitive Systems Engineering. New York: John Wiley & Sons, Inc., 1994. Salvendy G (Ed.). Handbook of Human Factors and Ergonomics (2nd Ed.). New York: John Wiley & Sons. 1997. Proctor RW & Van Zandt T. Human factors in simple and complex systems. Boston, MA: Allyn and Bacon. 1994. Sanders MS & McCormack EJ. Human factors in engineering and design (7th Ed.). New York, NY: McGraw-Hill. 1993.