Eric Shaver

Human Factors Professional

Health Care Needs Human Factors Professionals

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Medical Team Working On Patient In Emergency Room

Overview

In November 1999, the Institute of Medicine (IOM) released a report entitled, “To Err is Human: Building a Safer Health System,” in which they reported that between 44,000 and 98,000 patients die each year in U.S. hospitals due to medical errors.  Although this revelation took many in the health care community by surprise, there were individuals sounding the alarm in the past (e.g., Cooper, et al., 1978; Leape, 1994).  Moreover, Lucian Leape understood that methods from human factors might facilitate a decrease in medical errors when he stated:

“Can the lessons from cognitive psychology and human factors research that have been successful in accident prevention in aviation and other industries be applied to the practice of hospital medicine? There is every reason to think they could be” and “Error prevention strategies for the practice of medicine can be modeled after the theories of cognitive psychologists and human factors engineers” (Leape, 1994).

History of Health Care and Human Factors

The human factors discipline has been interested in understanding and mitigating the occurrence of human error within complex systems for decades (e.g., Norman, 1981; Reason, 1990).  With respect to health care, although research was performed within the discipline prior to the IOM report (e.g., Bogner, 1994; Cook, et al., 1998), it didn’t move to the forefront until the beginning of the 21st century.  Some of the actions that brought it into the spotlight included an editorial by the Human Factors and Ergonomics Society (HFES, 2000, February), an opinion piece by a former president of the Society (Woods, 2000, May), and the creation of a Task Force on Health Care (HFES, 2000, October).

The HFES has been a driving force in facilitating the advancement of health care human factors for a number of years. For instance, the Health Care Technical Group with 600+ members “…is interested in maximizing the contributions of human factors and ergonomics to medical systems’ effectiveness, patient safety and the quality of life for people who are sick or functionally impaired.  We seek to bring together people who share our interests.” Also, starting in 2012, the Society has held annual symposia that bring together human factors professionals from around the world to meet and share their latest research. The 2015 Symposium on Human Factors and Ergonomics in Health Care: Improving the Outcomes will feature health care topics in four tracks: Health-Care Provider and Patient Safety; Clinical and Consumer Health-Care IT; Medical and Drug Delivery Devices; and Clinical Care Settings.

Human Factors Areas of Focus in Health Care

The last 15+ years has seen significant human factors research and interventions focused on a variety of domains, topics, and targets, including:

  • People (e.g., nurses, patients, pharmacists, physicians, technicians, etc.)
  • Specialties (e.g., anesthesiology, critical care, emergency medicine, gynecology, nursing, pharmacy, radiology, surgery, etc.)
  • Settings (e.g., emergency departments, home care, intensive care units, nursing homes, operating rooms, pharmacy departments, physician offices, etc.)
  • Topics (e.g., build environment, care coordination, checklists, health information technology, infection prevention, medical devices, medication, organizational culture, patient satisfaction, simulation, teamwork, telemedicine, training, etc.)

More Work Is Needed

While human factors professionals have made great strides in assisting the health care community with mitigating the negative consequences of medical error, additional work is still needed.  As noted by Woods (2000, May), “Health care is an opportunity for human factors, but only if we are up to the sacrifices involved in building, extending, and deepening the ways we can help people create safety” (p. 5). I have no doubt that the our professionals are up to the challenge of tacking this worthy endeavor and working with others to provide practical solutions that can be implemented by the health care community.

To Learn More

Interested readers are encouraged to review the following resources to learn how human factors researchers and practitioners have assisted with decreasing medical errors and increasing patient safety within health care while also increasing efficiency and decreasing overall costs.

Books

  • Carayon, P. (2011).  Handbook of human factors and ergonomics in health care and patient safety (2nd ed).  Boca Raton, FL: CRC Press.
  • Dekker, S. (2011). Patient safety: A human factors approach. Boca Raton, FL: CRC Press.
  • Reason, J. (2008). The human contribution. Burlington, VT: Ashgate Publishing Company.
  • Salas, E., Frush, K., Baker, D.P., Battles, J.B., King, H.B., & Wears, R.L. (2013). Improving patient safety through teamwork and team training. New York, NY: Oxford University Press.
  • Woods, D.D., Dekker, S., Cook, R., Johannesen, L., & Sarter, N. (2010). Behind human error. Burlington, VT: Ashgate Publishing Company.

Chapters

  • Carayon, P., Alyousef, B., & Xie, A. (2012). Human factors and ergonomics in health care. In Gavriel Salvendy (Ed.), Handbook of Human Factors and Ergonomics, 4th (pp. 1574-1595).
  • Morrow, D., North, R., & Wickens, C.D. (2005).  Reducing and mitigating human error in medicine.  In R.S. Nickerson (Ed.), Reviews of Human Factors and Ergonomics, Vol. 1 (pp. 254-296).  Santa Monica, CA: Human Factors and Ergonomics Society.

Reviews

  • Morrow, D.G. (Ed.). (2013). Reviews of Human Factors and Ergonomics (Vol. 8). Santa Monica, CA: Human Factors and Ergonomics Society.

Journals

  • Bagnara, S. (2007).  Patient safety – An old and a new issue.  Theoretical Issues in Ergonomics Science, 8, 365-369.
  • Barach, P. (2007).  A team-based risk modification programme to make health care safer.  Theoretical Issues in Ergonomics Science, 8, 481-494.
  • Buckle, P., Clarkson, P.J., Coleman, R., Ward, J., & Anderson, J. (2006).  Patient safety, systems design and ergonomics.  Applied Ergonomics, 37, 491-500.
  • Carayon, P., Wetterneck, T.B., Rivera-Rodriguez, A.J., Hundt, A.S., Hoonakker, P., Holden, R., & Gurses, A.P. (2014). Human factors systems approach to healthcare quality and patient safety. Applied Ergonomics, 45, 14-25.
  • Friesdorf, W., Buss, B., & Marsolek, I. (2007).  Patient safety by treatment standardization and process navigation – A systems ergonomics management concept.  Theoretical Issues in Ergonomics Science, 8, 469-479.
  • Healey, A.N., & Vincent, C.A. (2008).  The systems of surgery.  Theoretical Issues in Ergonomics Science, 8, 429-443.
  • Karsh, B., Holden, R.J., Alper, S.J., & Or, C.K.L. (2006).  A human factors engineering paradigm for patient safety: Designing to support the performance of the healthcare professional.  Quality and Safety in Health Care, 15 (Suppl I), 59-65.
  • Leape, L.L. (2004, Summer).  Human factors meets health care: The ultimate challenge.  Ergonomics in Design, 6-12.
  • Russ, A.L., Fairbanks, R.J., Karsh, B., Militello, L.G., Saleem, J.J., & Wears, R.L. (2013). The science of human factors: Separating fact from fiction. BMJ Quality and Safety, 22, 802-808.
  • Salad, E., Baker, D., King, H., & Battles, J. (2006).  Special section commentary: Opportunities and challenges for human factors and ergonomics in enhancing patient safety.  Human Factors, 48, 1-4.
  • Salas, E., Rosen, M.A., & King, H. (2007).  Managing teams managing crises: Principles of teamwork to improve patient safety in the emergency room and beyond.  Theoretical Issues in Ergonomics Science, 8, 381-394.
  • Schutz, A.L., Counte, M.A., & Meurer, S. (2007).  Assessment of patient safety research from an organizational ergonomics and structural perspective.  Ergonomics, 50, 1451-1484.
  • Weaver, S.J., Salas, E., & King, H.B. (2011). Twelve best practices for team training evaluation in health care. The Joint Commission Journal on Quality and Patient Safety, 37, 341-349.

Proceedings

Websites

References

Bogner, M.S. (Ed.). (1994). Human error in medicine. Hillsdale, NJ: Lawrence Erlbaum Associates.

Cook, R.I., Woods, D.D., & Miller, C. (1998).  A tale of two stories: Contrasting views of patient safety. Boston, MA: National Patient Safety Foundation.

Cooper, J.B., Newbower, R.S., Long, C.D., & McPeek, M. (1978).  Preventable anesthesia mishaps: A study of human factors.  Anesthesiology, 49, 399-406.

Human Factors and Ergonomics Society (2000, February).  Patient safety and human factors/ergonomics.  Human Factors and Ergonomics Society Bulletin, 43(2), 1-2.

Human Factors and Ergonomics Society (2000, October).  Human factors and patient safety, continued.  Human Factors and Ergonomics Society Bulletin, 43(10), 1-2.

Kohn, L.T., Corrigan, J.M., & Donaldson, M.S. (Eds.). (2000). To err is human: Building a safer health system. Washington, D.C.: National Academy Press.

Leape, L.L. (1994).  Error in medicine.  The Journal of the American Medical Association, 272, 1851-1857.

Norman, D.A. (1981).  Categorization of action slips.  Psychological Review, 88, 1-15.

Reason, J. (1990).  Human error. New York, NY: Cambridge University Press.

Woods, D.D. (2000, May).  Patient safety and human factors opportunities.  Human Factors and Ergonomics Society Bulletin, 43(5), 1; 4-5.

Warren Bennis, A Leader Worth Emulating

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Warren Bennis Books

Warren G. Bennis, noted leadership scholar and educator, passed away on July 31st at the age of 89.

I first read On Becoming a Leader in the early 2000s. To say it had a profound impact on my thinking about leadership, would be an understatement. From there I read Organizing Genius: The Secrets of Creative Collaboration, along with several magazine and journal articles dating back to the late 1950s. In 2011, I read his entertaining and thought-provoking autobiography Still Surprised: A Memoir of a Life in Leadership.

While I never had the privilege of meeting the man, I was able to admire his wisdom and guidance from afar through his numerous publications. Many of his insightful passages have been added to my collection of leadership quotes (see here, here, and here for examples). His passing is a loss for the leadership community.

To learn more about his life and legacy, I would encourage you to read the following:

Human Factors Should Contribute to Company Strategies

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The July 2009 issue of Applied Ergonomics includes an article entitled, “Ergonomics Contributions to Company Strategies,” by Jan Dul and W. Patrick Neumann.

The authors contend that one of the reasons why human factors and ergonomics hasn’t seen greater acceptance within the business community stems from a failure to explicitly demonstrate how interventions support company strategies and business goals.  Moreover, they state:

  • “…if ergonomics contributes directly to the company’s strategy, and in the language of the company, it will be more accepted by business managers; it will be better embedded (internalized) in the organization; and its full potential as described in the IEA definition [5] will be better actualized.” (p. 746)
  • “…attention to ergonomics can be an important element of how a company realizes its competitive advantage.” (p. 749)
  • “Capturing the full benefits of ergonomics therefore will require the deliberate integration of ergonomics into core strategy arenas of the organization.” (p. 749)
  • “…we believe that explicit linking of ergonomics to the strategy and desired business outcomes is a promising way to realize sustainable growth for firms without the high social costs due to work-related ill health.” (p. 749)

The authors divide the concept of strategy into three areas where human factors and ergonomics can add value, including:

Business Function Strategies and Ergonomics

  • Product design and innovation – “…ergonomics can be linked to strategies for product design and innovation by assuring that the products fit with the end-users and are easy to produce.” (p. 747)
  • Operations engineering and process innovation – “…ergonomics can be linked to strategies for operations engineering and process innovation in order to assure that both production goals and worker well-being are safeguarded.” (p. 748)
  • Marketing and communication – “…ergonomics can be linked to marketing and communication strategies by providing reasons for positive (well-being) consumer associations with the company’s products and production processes.” (p. 748)
  • Human resource management – “…ergonomics can be linked to HRM strategies by assuring good working conditions and by engaging in participatory and job design approaches.” (p. 748)

Cross-Functional Strategies and Ergonomics

  • Downsizing, lean production, business process re-engineering – “…ergonomics may help companies to control the negative human effects of the downsizing, lean production and business process re-engineering strategy in order to obtain the real benefits from this strategy.” (p. 748)
  • Total quality management – “…ergonomics may contribute to TQM by ensuring that people contribute to quality.” (p. 749)

Corporate Strategies and Ergonomics

  • Differentiation strategy – “…ergonomics could be linked to a company’s differentiation strategy by adding user-friendly and affective features to products and services.” (p. 749)
  • Cost strategy – “…ergonomics could be linked to a company’s cost strategy by increasing labor productivity and reducing labor costs.” (p. 749)
  • Resource-based view of the firm – “…ergonomics, with its ability to support employee retention, can help provide firms with a sustainable competitive advantage in the form of experienced, skilled employees who can perform their best for the company.” (p. 749)
  • Service profit chain – “…by increasing employee wellbeing, ergonomics can be linked to a service profit chain strategy.” (p. 749)

The authors also address a couple key points to human factors and ergonomics researchers, educators, and practitioners, including:

  • “We believe that ergonomists in research, education and practice (both internal ergonomists that are part of the organization and external consultants), who accept the broad definition of ergonomics presented in the introduction have a crucial role in: (a) developing the possible links between ergonomics and company’s strategies; (b) finding evidence for these links; and (c) communicating the links to the business stakeholders who are involved in strategy formulation and implementation.” (p. 750)
  • “The successful ergonomist in research, education or practice is aware of business strategies and desired business outcomes; knows who are main stakeholders; knows what the benefits of ergonomics may be for these stakeholders; knows how ergonomics can be implemented to realize these benefits; and can communicate with the stakeholders in their own language and networks.” (p. 750)

References

Dul, J. & Neumann, W.P. (2009). Ergonomic contributions to company strategies. Applied Ergonomics, 40, 745-752.

Best Practices for Health Care Team Training Evaluation

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Weaver, et al. (2011) published an article, entitled “Twelve Best Practices for Team Training Evaluation in Health Care,” in The Joint Commission Journal on Quality and Patient Safety.

The article intends to identify best practices for health care team training evaluation based upon nearly three decades of research and practice. Specifically, the authors state:

“Our goal is not to present a new methodology for evaluation but to distill principles from the science and temper them with the practical considerations faced on the front lines, where evaluation efforts compete with limited human, financial, and time resources” (p. 342).

They go onto clarify that:

“Although the 12 best practices may be perceived as intuitive, they are intended to serve as reminders that the notion of evidence-based practice applies to quality improvement initiatives such as team training and team development as equally as it does to clinical intervention and improvement efforts” (p. 341).

The twelve best practices, arranged according to three phases of training (Planning, Implementation, & Follow-Up), are:

Planning

  • Best Practice 1. Before designing training, start backwards: Think about traditional frameworks for evaluation in reverse.
  • Best Practice 2. Strive for robust, experimental design in your evaluation: It is worth the headache.
  • Best Practice 3. When designing evaluation plans and metrics, ask the experts—your frontline staff.
  • Best Practice 4. Do not reinvent the wheel; leverage existing data relevant to training objectives.
  • Best Practice 5. When developing measures, consider multiple aspects of performance.
  • Best Practice 6. When developing measures, design for variance.
  • Best Practice 7. Evaluation is affected by more than just training itself. Consider organizational, team, or other factors that may help (or hinder) the effects of training (and thus evaluation outcomes).

Implementation

  • Best Practice 8. Engage socially powerful players early. Physician, nursing, and executive engagement is crucial to evaluation success.
  • Best Practice 9. Ensure evaluation continuity: Have a plan for employee turnover at both the participant and evaluation administration team levels.
  • Best Practice 10. Environmental signals before, during, and after training must indicate that the trained KSAs and the evaluation itself are valued by the organization.

Follow-up

  • Best Practice 11. Get in the game, coach! Feed evaluation results back to frontline providers and facilitate continual improvement through constructive coaching.
  • Best Practice 12. Report evaluation results in a meaningful way, both internally and externally.

References

Weaver, S.J., Salas, E., & King, H.B. (2011). Twelve best practices for team training evaluation in health care. The Joint Commission Journal on Quality and Patient Safety, 37, 341-349.

James MacGregor Burns on Leadership

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Leadership - James MacGregor Burns

Earlier this week, noted biographer and leadership scholar, James MacGregor Burns, PhD. passed away at the age of 95 (see here and here for details about his life).

Arguably one of Dr. Burns greatest contributions to the discipline is his 1978 book Leadership where he coined the terms transactional leadership and transformational leadership.  If you’ve never read it, I encourage you to do so.

One of my favorite quotes, which is still relevant today as it was more than 35 years ago, is:

“The crisis of leadership today is the mediocrity or irresponsibility of so many of the men and women in power, but leadership rarely rises to the full need for it. The fundamental crisis underlying mediocrity is intellectual. If we know all too much about our leaders, we know far too little about leadership. We fail to grasp the essence of leadership that is relevant to the modern age and hence we cannot agree on the standards by which to measure, recruit, and reject it. Is leadership simply innovation – cultural or political? Is it essentially inspiration? Mobilization of followers? Goal setting? Goal fulfillment? Is a leader the definer of values? Satisfier of needs? If leaders require followers, who leads whom from where to where, and why? How do leaders lead followers without being wholly lead by followers? Leadership is one of the most observed and least understood phenomena on earth.” (pp. 1-2)

References

Burns, J.M. (1978).  Leadership.  New York, NY: Harper & Row.