Crucial Conversations. Embracing Human Factors Crucial Conversation and Considerations. A topic introduction

Transcription

1 Crucial Conversations Embracing Human Factors Crucial Conversation and Considerations A topic introduction Professor Jane Reid Clinical Lead Wessex Patient Safety Collaborative 1

2 Session Objectives By the end of this session participants will be able to Define Human Factors/Ergonomics Consider how they impact outcomes of care Explain two methods to assess the work environment for violations and argue the case for Human Factors awareness across the workforce List 3 factors that impact human performance Consider application and practice

3 Health Warning

4 The Science of Human Factors & Ergonomics Extensive research and application and evolving at a rapid rate

5 Ground rules

6 Ice-breaker - Our Context Think about a working day last week What were the things that made it difficult to do your job do the right thing do things as you would professionally wish them to be done/delivered? Reflect for a moment and then discuss on your tables, identify 3 key challenges you would like to share with the room

7 Human Factors definition Human factors encompasses all of those factors that can influence people and their behaviour. In a work context, human factors are the environmental, organisational and job factors and individual characteristics which influence behaviour at work. Clinical Human Factors Group. 2009

8 Clinical human factors : enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities, and application of that knowledge in clinical settings. Catchpole K (2010)

9 HFE & QI HFE explores a problem by looking at the people within a system, their interactions with each other and the system and then redesigning the tasks, interfaces and system. HFE assists structuring improvement based on an appreciation of human capabilities and limitations

10 Crucial Conversations Why is Human Factors important in a Mental Health Context? Setting the organisational culture Support for front line clinical teams Not just about patient safety Assurance 10

11 Crucial Conversations Setting the Example Open, transparent approach Profile of patient safety and quality Support for staff to speak out Roles and relationship The human impact 11

12 Crucial Conversations Context of Healthcare 2017/18 The Legacy of Mid Staffs Inquiry / Morecombe Bay and Winterbourne View Contradictions and Challenges NQB Concordat for Human Factors in Healthcare Health Investigation Branch Just Culture Human Factors Informed Policy 12

13 How safe is my organisation, (use a x) 1 (low) 10 (high) How safe is it to speak up in my organisation 1 (low) 10 (high)

14 Discuss for 5 mins and be prepared to share with the room three issues common to you all. Table Top Exchange What keeps you awake at night? Do similar issues keep your colleagues awake? What mechanisms exist in the organisation to discuss and address?

15 Human Cognition & Fallibility

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18 Humans are pattern matchers Aoccdrnig to a rscheearch at Cmabrigde Uinervtisy, it deosn't mttaer in waht oredr the ltteers in a wrod are, the olny iprmoetnt tihng is taht the frist and lsat ltteer be at the rghit pclae. The rset can be a toatl mses and you can sitll raed it wouthit porbelm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe.

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23 Inattentional blindness 83% radiologists did not see the gorilla Gorilla = 48X size of nodule on a CT scan Don t see what you are not expecting to see Drew, Vo and Wolfe (2012)

24 Selective Deafness

25 Voluntary Automaticity Filter Models of Attention

26 Confirmation Bias Confirmation Bias is the technical name for the attention to data that support the presumed diagnosis and minimising data that contradict it. How Doctors Think by Jerome Groopman M.D

27 Situational Awareness

28 Good Situational Awareness?

29 Escalation and navigating Hierarchy and work based tension

30 Rasmussen s Skill, Rule and Knowledge (SRK) model Conscious Thought Skill Rule Automatic, familiar & well practiced routines Learning rules and rehearsing routines Novel task Knowledge

31 Unacceptable variation in quality of patient experience and clinical outcome

32 Recognising the problem? It is not generally recognised that a significant number of patients are harmed not as a result of underlying illness, or disease, but as a result of their treatment Vincent et al 2001

33 Understanding the problem Analysis of AE s/harm highlights that nontechnical aspects of performance and team relationships play a contributory role in the multi-faceted nature of adverse events Vincent 2001

34 Human Factors in Safety (30-20%) Technical Factors Accident Causation (70-80%) Human Factors

35 Human Factors in Safety (30-20%) Technical Factors Accident Causation (70-80%%) Human Factors Organisational / Safety Culture = + Operator Behaviour

36 Human Factors in Safety (30-20%) Accident Causation Technical Factors Pre-disposing conditions that increase the potential for violations (70-80%%) Human Factors Organisational / Safety Culture = + Operator Behaviour

37 Human Factors in Safety (30-20%) Accident Causation Technical Factors stress, pressure, demand, capacity, capability (70-80%%) Human Factors Organisational / Safety Culture = + Operator Behaviour

38 some stories..

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41 Total lives lost per year 100,000 10,000 1, HAZARDOUS (>1/1000) Health Care Mountain Climbing Bungee Jumping REGULATED Driving Chemical Manufacturing Chartered Flights ULTRA-SAFE (<1/100K) Scheduled Airlines European Railroads Nuclear Power ,000 10, ,000 1million 10million Number of encounters for each fatality

42 Avoidable Harm The size of the problem?

43 Healthcare Systems Input? Output

44 Sources of system error/failure Multiple players with potentially different goals and assumptions Safety features, defenses become degraded over time Environmental conditions, expectations, and demands change over time

45 Sources of system error/failure Actual operations are more complex than our design models System elements interact in unexpected ways Procedures, tools, and materials are used in ways not anticipated

46 Behaviours contributing to error/harm failures in decision making poor teamwork deficits in interpersonal skills lapses in situational awareness lack of coordination or cooperation lack of clarity of, or ineffective leadership inconsistencies in process/procedure Gawande et al 2003, Studdert et al 2006, Christian et al 2006,

47 Catchpole et al. (2006). Identification of systems failures in successful paediatric cardiac surgery. Ergonomics 49(5-6).

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49 James Reason Collective mindfulness Humans as hazards humans as heroes

50 Safety 1 and the Swiss cheese model

51 Table top scenario for discussion and plotting onto the Swiss Cheese Model

52 Swiss Cheese in Real Life

53 The nature of work What management thinks happens Work as imagined Management Gap What actually happens Work as done Gap between work descriptions and work as it is actually done

54 Resilience/Safety 2 The ability to make decisions and direct (the limited) resources to minimise the risk of harm, knowing that the system (hospital/service/gp Practice) is compromised because it includes sometimes faulty equipment, imperfect processes, and fallible human beings

55 Resilience/Safety 2 A resilient system (hospital/service/gp Practice) is one that continually revises its approach to work in an effort to prevent or minimise failure Constantly aware of the potential for failure

56 Resilience/Safety 2 We need to recognise that safety and error/avoidable harm come from the same place

57 The nature of work What management thinks happens Management Gap? What actually happens Informal work systems Safety

58 Resilience/Safety 2 We need to recognise that safety and error/avoidable harm come from the same place

59 Violation & Migration A source of Avoidable Harm and Institutional Failure

60 Human Factors/Ergonomics... An organising principle

61 Discussion Point Do you know when the organisation/individual services/units of care, are at the margins of safety? How do you know if the margins of acceptable care are under threat and/or breached? Does the Board and Senior Management acknowledge and own the organisations productivity/safety trade-offs? How are the impacts of trade offs measured? What is the point at which you will stop the line?

62 Who in the room always drives within the required speed limit?

63 Systemic Migration to Boundaries INDIVIDUAL BENEFITS VERY UNSAFE SPACE Driving 90 mph the illegalillegal space (for almost all of us!) Driving 75 mph- the Illegalnormal space The speed limit is 70 mphthe legal space Life Pressures Perceived vulnerability Belief Systems ACCIDENT PERFORMANCE

64 Managing Behavioural Choices: Everyone Takes Risks, Every Day RISK SOCIAL UTILITY

65 Q&A What risks have you taken/or are you taking? Are you confident that you can discriminate the risk thresholds for the organisation?

66 Q&A Do you know where your organisation and its people drift? Are you confident that everyone appreciates what drift is? How close to the margins of safety are you prepared to drift? What is your thermostat for margin assessment? How confident are you that drifting is a tightly managed exception vs the organisational norm - simply the way we do things around here

67 How does this happen?

68 Systemic Migration to Boundaries INDIVIDUAL BENEFITS VERY UNSAFE SPACE Patient nursed in store cupboard the illegalillegal space (for almost all of us!) ACCIDENT Patient admitted to a bed but the mixed sex rule is breached illegal-legal space (for almost all of us!) Patient gets to an appropriate bed within 4 hours the legal space Performance targets Perceived vulnerability Service Pressures & Belief Systems PERFORMANCE

69 Table Top Discussion Are there recognised violations and routine work arounds in your area of work? Are they generally known and understood/routinely practised? How far do staff routinely or by exception in extremis migrate to the margins of safety? Are these practices recognised by the senior leadership in your organisation? How do these practices relate to your rating of how safe your oganisation feels and safe you feel it is to speak up in your organisation? 69

70 Managing Migrations INDIVIDUAL BENEFITS VERY UNSAFE SPACE 4. Agreed forbidden space for all staff Add defences and Just Culture 3. Forbidden space, except under extreme pressure/ conditions Illegal-Illegal Space Never/ Sometimes ACCIDENT 2. Acknowledge individual variation in risk acceptance. System response required Suppress triggering conditions Build Human Factors Reliability illegal normal space (for most of us) always/ sometimes! 1. Individual or collective experience of incidents, share stories Agree stop rule to migration Expected safe legal space as defined by professional standards Accept and adapt protocols and defences PERFORMANCE

71 patients and families.. the human impact