Welcome to this session on human factors. I'm Melody Malone, a Quality Improvement Consultant with TMF Health Quality Institute, and so glad that you are going to learn about human factors and how they can help your root cause analysis. Hopefully have reviewed the Root Cause Analysis video and the just culture, or you will as you move forward in your Quality Improvement Effort. They all go together in helping you identify your true root causes. But before we go further let us discuss how learning from the data can be an important effort in your quality improvement activities. But we must never forget that every piece of data, every opportunity for quality improvement may have actually hurt a human being. Every resident matters, every staff member matters and every visitor and guest matters. So as we learn from our human factors, let's keep this in mind. Professor Senders writes in his chapter on Failure Mode and Infects Analysis in Medicine that, "Human errors are NOT drawn from an infinite set of possibilities. Instead they are drawn from a limited set of meaningful things that an individual can do in any defined situation. So, as in Murphy's Law: If something can go wrong, it will; the task in the first instance is to discover what can be done wrong." And then in the second instant, "predict what will happen when it is done." When we do those things, we can identify the problems on psychology and engineering that are causing our clinical errors in medicine. Now we're going to try watching a movie and I hope as your team watches this movie, you will jot down a few things that you might see as it is full of human factors.
All right girls, listen carefully. This is the wrapping department.
Yes ma'am.
Now, the candy will pass by on this conveyor belt and continue into the next room where the girls will pack it. Now your job is to take each piece of candy and wrap it in one of these papers and then put it back on the belt. You understand?
Yes sir. Yes ma'am!
Let 'er roll! [laughter] Let 'er roll! Well, wait here. Somebody is asleep at the switch!
[Laughter]
What are you doing up here? I thought you were downstairs boxing chocolates.
OH they kicked me out of there fast.
Why?
I kept pinching them to see what kind they were. [laughter] This is the fourth department I've been in.
I didn't do so well either.
All right, girls. Now this is your last chance! If one piece of candy get past you, and into the packing room unwrapped, you're fired!
Yes ma'am!
Let 'er roll!
[ Noise & Laughter ]
Oh. This is easy!
Yeah. We can handle this okay!
[ Noise ]
Listen, Ethel, I think--
[ Noise ]
I think we're fighting a losing game.
Here she comes!
[ Noise ]
Fine, you're doing splendidly! Speed it up a little.
[ Laughter & Noise ]
Well hopefully as you quit laughing, you would have an opportunity or had an opportunity jot down a few ideas. Tell me about what human factors did you see. And this might be a great time of you're with the team to spot this program and discuss it, after you quit laughing. But I notice that there was a do or die physician. This is your last chance. Is this a positive or negative motivator for your staff when things like that are said? What sort of pressure does that put them under? And did you notice, Ethel and Lucy didn't really have any real training. The supervisor didn't even show them an example of what to do or how to warp the candy. And I notice inconsistencies in product placement on the conveyor belt. The candies came through at random distances. I'm not sure there was quality there. And did you hear that "We're fighting a losing game!", but they didn't speak up. Why is that? Fear of losing their jobs? Fear of failure? Fear of retaliation from the supervisor? And what about "Speed it up"? The supervisor is sharing nothing, sees nothing as well, and speeds it up. So Lucy and Ethel will never be successful. They're destined to fail. How many times do we do that in nursing home? Do your processes set people up for failure? Are the expectation such that no one could reach them, much less met them consistently? This sorts of human factors are what cause errors today, not only in our industry, but in all areas, even our home. So when we're thinking about human error, the old view is that there's a bad apple, right? That everything would be fine if it weren't for unreliable people or human errors cause accidents, or failures or surprises. But when we frequently look at the person, most associated with the clinical error, as in such a wrong patient, wrong drug or treatment, wrong dose format, we find that when we're only looking at the person involve that we miss looking at other system components that may have contributed to the error. What about the prescribers or other dispensers, such as pharmacy, the resident themselves. Regulatory agencies, administrators help systems operators and managers. There're many things that go into looking at the human error. But what's wrong with this older view? Well, when were focusing strictly on individuals, we're not really solving the underlying problem. And the old view offices that, errors are not intrinsically bad. But if we learn more about the system that we're working within, every time we identify an error, then we get better identify method to minimize those negative outcomes or errors. So when we think about human error, when we acknowledge human error, we can then see that we can get to sustainable improvement. We need to accept that human error is present and when we recognize it as part of the process; we can then begin to find ways to potentially overcome it, because it is not random. And it really isn't the conclusion of an investigation. It is just the beginning, because human error is a symptom of deeper trouble. So what is human factor? Well human factors are the tools and task and the work environments that influence what we do and how we do it. Think about your car, if you get in your car and start driving off, what almost immediately starts happening? The seatbelt alarm starts going off, right? Well that's a built-in safety mechanism to help us in our business.
^M00:10:05 When we might forget to snap out seatbelts in place, the alarm there is to remind us because we know seatbelts save lives. So that's a human factor. The alarm is a human factor that helps us overcome our barriers to snapping our seatbelt every time. So human factors really is about how we design our workplace, our tools, and our processes. And the impact that that design has on errors or elimination of errors. So take a look at this picture. What is wrong with this picture? I mean what would you do at this point? Are you going to keep right? Or are you going to turn left? The very time to using sign. But when we think about how could this have happened. Well it may have been a distracted sign maker. And what happens to the people that actually put it up? And what could happen as the result? And what are the characteristics of the task? When we think about that we realize that human factors could really make a difference in this sign. How complicated is the task for the driver? How distracted are they when this-- when they approach this sign? And what could have happened with the sign maker, were they distracted when they were making the sign? So in order to combat human error with better designs, we have to realize a couple of things. We have to assume that people do reasonable things. And we have to look at why there's a performance gap. So within each of you, you need to decide within yourself it is, if you believe that it is possible that most people show up everyday to do their job to the best of their ability. If they do then we have to look at why there is performance gap. And there are three categories, a planning error, and execution error, and a violation. And we're going to walk to those now. So planning error, let's say you want to drive to your favorite gas station to get your gas, but you run out of gas, bad plan, right? So the plan was inadequate to achieve the desired outcomes. This could happen too, in such a thing as reducing a restraint. And the resident fell. The plan may have been inadequate to get that restraint reduced without an error. So when is it a planning error? Well, it's when you hear things like, I didn't know what do, how to do it, who is suppose to do it, I couldn't do it, or used to do it differently. Those would be verbal cues that you might hear from someone when it's a planning error. So I want you to take a moment if you're with the team and discuss what sort of planning errors have you experience lately. And then come back to us. Welcome back. Well what may not work in planning errors is punishment, rewards and reminders. Remember they believe that they were acting correctly that they've felt like the plan was going to be adequate. So what we have to do is redesign the plan to make sure that it's adequate, and be sure that we get plenty of training and education, and maybe even some memory aids, step-by-step guides to get through the plan. Now let's discuss execution errors. This is when the plan was not executed properly. So we had a good plan but it wasn't executed properly. So we wanted to turn left or right, or which one was it. So out plan was to turn left but we turned right; or giving the wrong medication when distracted or forgetting to assess the resident's pain, maybe due to interruption. So those would be thing that were just execution. We know that right thing to do, but we've forgot, or we got distracted. Or it looked alike, the steps look alike, or I just messed up. Those would be the things you hear from your staff. So talk among your team about what sort of execution errors you may have experienced lately. And welcome back to what may not work for execution errors; punishment or rewards or training particular with skilled operators or experts because they intended to correctly complete that task, right? It's just that the plan wasn't executed correctly. So these things may not work. But what might work would be prompts, reminders or aid, sort of like the seatbelt. We all know that the plan is to snap the seatbelt, but we just forget to do it some times. So that's an idea of how you can fix an execution error. But a violation--a violation is different. This is when they deliberately moved away from what is the usual safe practice. They don't intend any negative consequences. So a violation is very different and that is deliberate. And there are certain conditions that are more likely to produce a violation. And that might be when people feel like their frustrated, the rules are cumbersome. They can save time doing it their way. Or they may have a perception of being above the rules. So talk about what sort of violations you've experienced lately. Now keep in mind we all do this, because how many of you have never run a red light? Or you've never wheeled up to a stop sign and gone right on? Or you've gone a little bit over the speed limit? So we all look at violation a little bit differently, because we're talking the risk that everything will be okay. So talk among your group and then come back. And welcome back. So here's what may now work. Is any kind of training or reminders or aids or even punishment, because keep in mind this was a deliberate departure from the expected practice. So it was a positive reinforcement for me to actually save time by doing it my way. So that positive consequence is very strong for me to continue violating. So we have to come up with something else. And that something else would be redesign he work to eliminate those frustrations. Use positive feedback when you get to the desired behavior. Simplify those process and use policies and rules only when necessary. Which I realize is kind of funny in long term care, or healthcare, because we've got lots of policies and procedures and rules. But we want to use them only when necessary, that our steps have some flexibility to get their job done. So in summary, there're all kinds of solutions that you can up with human factor. But first you have to decide within yourself that most people show up everyday to do the job right. When there is an error, we have to dig deep in that root cause analysis and look at human factors, and try to determine, is there a planning error, an execution error, or a violation that we need to address? So review a recent problem for the human factors. Look at your last root cause analysis. Did you consider human factors? Remember the things you saw on the Lucy video. What are barriers to success? And view this session on just culture. It will help you a little bit more with the issue of violation. And then contact us if we can help you and remember we have tons of resources available for you in your quality improvement work.