Human Factors Engineering in Health Care. Awatef O. Ergai, PhD Post-Doctoral Research Associate Healthcare Systems Engineering Institute
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1 Human Factors Engineering in Health Care Awatef O. Ergai, PhD Post-Doctoral Research Associate
2 Outline 1. What s human factors engineering (HFE) 2. Why is human factors engineering important in health care 3. Patient safety 4. IT in HC 5. Navigating Health Systems 2
3 What s HFE? Human + Factors + Engineering 3
4 What s HFE? Using knowledge about human capabilities, abilities, and limitations 5 senses communication styles ranges in physical size and strength Designing things or processes to fit human abilities and limitations Using specific ways to uncover hidden needs, assumptions and unexpected interactions, e.g. Mental work load techniques Task analysis Usability testing 4
5 What s Human Factors? Human Factors (or ergonomics) is the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data, and other methods to design in order to optimize human well-being and overall system performance. International Ergonomics Association, 2000
6 Organization Environment (Technology, tools, people) physical, Cognitive Scope of Human Factors Engineering 6
7 Psychology Industrial Design Industrial Engineering Human Factors Physiology Biomechanics Computer Science 7
8 People involved in Health Care Are Diverse: Healthcare providers and workers Patients Families All have varied: Needs Abilities Limitations that change over time 8
9 Healthcare systems Healthcare PEOPLE education, training, orientation, MATERIALS medications, supplies, TOOLS Medical equipment, information technology, forms, communication materials METHODS procedures, diagnostic and treatment processes, management practices, policies, communications practices, coordination of effort, 9
10 Healthcare System An overloaded system Workflows and roles have not changed in the past couple of centuries Emphasis is placed on sickness control, not on health promotion The same challenges are faced everywhere, but are tackling them independently We cannot keep up with complex diagnostic and therapeutic technologies 10
11 Domains of HFE Physical Ergonomics: Focuses on the physical characteristic of the person Design of hospital facilities Design of physical environment Patient handling Macroergonomics: Focuses on the psychosocial characteristic of the person Job stress and burnout Teamwork Work schedules Cognitive Ergonomics: Focuses on the cognitive characteristics of the person Human Error 11
12 12
13 Why Human Factors Engineering in HC -vo&list=ple9858c8933d0411f 13
14 Cost Impacts Centers for Medicare and Medicaid Services (CMS), more than one million patient safety incidents occurred to hospitalized Medicare patients in the US over the years 2002 to 2004, causing more than 250,000 deaths and costing $9.3 billion
15 Adverse Event Rates in Healthcare Cardiac Surgery Patient ASA 3-5 Himalaya mountaineering Microlight flights helicopters Fatal Iatrogenic adverse events Medical risk (total) Road Safety Chartered Flight Chemical Industry (total) Blood transfusion Anesthesiology ASA1 Civil Aviation Railways (France) No system beyond this point Nuclear Industry Very unsafe Ultra safe Risk Amalberti, R, Auroy, Y, Berwick, D, Barach, P. Five System Barriers To Achieving Ultra-safe Health Care. Annals of Internal Medicine, 2005;142:
16 Why do we fail? Current systems in healthcare are highly dependent on level 1 measures: intent vigilance hard work We focus on outcomes, so only measure the process where there is catastrophic failure We miss process defects where the patient does well despite the system We don t really analyse failures and learn from them systematically
17 To Err is Human Doing tasks engages the cognitive characteristics of the person It involves perception, information processing, execution knowledge, and skills 17
18 Level of cognition required Performance How do we make decisions Automatic cognition Active problem solving Problem-solving is slow, conscious, sequential Skill-based Rule-based Knowledge-based
19 Are these lines straight? Optillusions.com
20 Cognition is Affected by Internal Factors Psychological states (anger, fear, boredom, anxiety) Physiological states (fatigue, illness) After one night of missed sleep - performance can decrease by 25% 17 hours awake is equivalent to a blood alcohol content of 0.05
21 The Stroop Test Please state the COLOR of the text Blue Red Green Black Green Blue Yellow Black Black Red Green Yellow Blue Green Black Red
22 22
23 Medication Labels DO----MINE - dopamine or dobutamine HY----ZINE - hydralazine or hydroxyzine 23
24 Cognition is Affected by External Factors Environmental factors (noise, heat, light) long work schedules inadequate training interruptions and distractions
25 Reason s Swiss Cheese Model (SCM) Latent Conditions Organizational Influences Latent Conditions Unsafe Supervision Latent Conditions Preconditions for Unsafe Acts Unsafe Acts Active Conditions Failed or absent defenses Accident 25
26 The System View of human error Human error is not the cause of events, it is a symptom of deeper troubles in the system Human error is not the conclusion of an investigation, it is the beginning Events are the result of multiple causes
27 Medication AEs Medication errors are the #1 cause of preventable AEs What do you notice in this picture? Enalaprilat is for high blood pressure Pancuronium is a muscle paralysis 27
28 How to design processes to reduce error? 1. Reduce reliance on memory Checklists Protocols Standardization Color matching Pre-packaging Automated reminders 2. Reduce reliance on vigilance Bar-coding Constraints Forced functions Color coding 3. Simplify tasks and processes 4. Reduce handoffs 5. Reduce the need for calculation 6. Provide adequate training 7. Manage fatigue 8. Provide adequate informational resources
29 29
30 Shift changes in hospitals Shift changes (handoffs, sign-outs) represent transitions that can impact the quality of patient care and patient safety Verbal handoffs Interruptions lead to diversion of attention, forgetfulness, and error Written handoffs Inconsistent Missing code status, allergies, age, sex 30
31 Communication examples Vague-- Patient got into a little trouble ; Mostly stable Ambiguous- Patient went south Confusing- He was all over the place but you don t have to worry about that Lack specificity- I gave him a little propofol Imprecise Analogies- He was like a roller-coaster Objectification and depersonification- The Gall Bladder in room 34 is doing fine 31
32 Hand-off as a Form of Communication 32
33 IPASS-SAFETY Nursing Handoffs 33
34 Information Technology 34
35 Why we need medical records? To: recall observations inform others gain knowledge monitor performance justify interventions instruct students 35
36 Information Technology Massive influx of computing technology into health care Electronic Health Records are a sea change in medicine Changes the way providers interact with patients each other their organizations 36
37 Building an Interconnected, Patient-Centric Care System
38 EHR Benefits Improved individual and population health outcomes Meaningful Use of EHRs Improved ability to study and improve care delivery Increased transparency and efficiency
39 EHR Benefits For Providers: Quick access to patient records from inpatient and remote locations for more coordinated, efficient care Enhanced decision support, clinical alerts, reminders, and medical information Performance-improving tools, real-time quality reporting Legible, complete documentation that facilitates accurate coding and billing Interfaces with labs, registries, other EHRs and HIEs For Patients: Reduced need to fill out the same forms at each office visit Reliable point-of-care information and reminders notifying providers of important health interventions Convenience of e-prescriptions electronically sent to the pharmacy Patient portals for online interaction with providers Electronic referrals allow for easier access to follow-up care with specialists
40 BUT 40
41 New Safety Concerns Emerging evidence suggest that EHR causes new safety concerns due to: Usability issues Disruptions of clinical processes Unsafe work-arounds to by-pass technology- related constraints EHR related safety concerns are multifaceted: Unsafe technological features of EHR EHR user behaviors Organizational Characteristics Rules and regulations that guide EHR related activities 41
42 42
43 Currently Functionality is quite fragile Design and functionality are not optimized Partially addresses the needs of healthcare providers
44 A potential vision of the future Fully integrated, multi-functional, multidisciplinary EHR capable of: capturing data at very frequent intervals (e.g. q minute) incorporating n-way real time dialog functions, multi-disciplinary decision support, full-scale acuity adjusted workload and care management capture with full data archiving and retrieval capacity
45 Navigating Health Systems 45
46 Signs Clear signage is extremely important in hospitals Why? Time spent in the hall can be life-threatening for patients who need immediate treatment Navigating a hospital can be confusing at best and infuriating at worst for families trying to locate the room of a loved one 46
47 How much time can be lost because of poor hospital signage? 30 % of first-time visitors and 15 % of repeat visitors reported navigation issues Staff reported spending an average of 2 4 mins per interaction providing directions to visitors 25 % of staff members admitted to not being able to find their own destination Maps are not always easy to follow Participants found difficulty with the inconsistent placement of signs and embedded signs with multiple levels of information 47
48 HFE Approach 1. Identify the best areas for signage. 2. The signs must be clear and easy to read 3. Signage must also be universal. use a consistent system Terms Colors Place of signs 48
49 Human Factors Engineering in HC Contributes to the safe design of healthcare systems by considering: The various needs Abilities And limitations of people involved in the system The quality and safety of care provided by healthcare systems are dependent on: the patient s risk factors the technical skills and knowledge of the healthcare staff, influenced by various characteristic of the system redesigned, changed and improved by applying HFE principles and methods 49
50 THANK YOU 50
51 51
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