9/29/2014 Systems Engineering Initiative SEIPS For Patient Safety - PDF document

9/29/2014 Systems Engineering Initiative SEIPS For Patient Safety APIC ‐ Palmetto Fall Educational Conference ‐ 2014 Understand the “System” Large scale issues in sociotechnical systems Human Factors 101 In Quality and IP we were trained to break down into parts…but in complex systems – Relationships between parts are far greater than the parts alone… 23 October 2014 Resilience …resilience aligns with what is described as a ‘‘new view of human error’’ which sees humans in Carla J. Alvarado, PhD a system as a primary source of resilience in creating safety. The ‘‘old view’’ focuses more on the elimination Research Scientist Emerita of risk rather than, more realistically describing University of Wisconsin-Madison strategy that will circumscribe, cope and contain Phone: 608.695.8746 failure, as proposed by resilience Email: calvarado@cqpi.engr.wisc.edu Systems Engineering Initiative SEIPS APIC-Palmetto Fall Educational Conference 2014 For Patient Safety In a Complex System Relationships between parts are Example far greater than the parts alone… Termite hill Can’t be reduced to the termites • Statistically emergent from termite • By the way there is no CEO termite or CNO-VP • patient services termite etc., just termites that all know their places and tasks in the system THE TERMITES HAVE A SHARED MENTAL MODEL We establish order and control through actions of a few top people in the organization – this may be the biggest factor holding back innovation and progress in our organizations Systems Engineering Initiative SEIPS Systems Engineering Initiative APIC-Palmetto Fall Educational Conference 2014 SEIPS APIC-Palmetto Fall Educational Conference 2014 For Patient Safety For Patient Safety “Whac-a-Mole” explained So what do we do? The prevailing • Try to predict where problem will be based healthcare prevention system paradigm: on past experience • Identify individuals involved Slide stolen from Matt Scanlon, MD • Determine they are at fault • Retrain them or even punish them • Failure? Do the same analysis all over again… 6 6 Systems Engineering Initiative APIC-Palmetto Fall Educational Conference 2014 SEIPS For Patient Safety 1

9/29/2014 Problems with the anticipatory model “Whac-a-Mole” is an Anticipatory Model This is an anticipatory model – based on prediction of problems occurring again…in the exact same way! You guess or try to “pattern match” (data) where the “mole will pop up” But…what is the problem with this model Systems Engineering Initiative Systems Engineering Initiative SEIPS APIC-Palmetto Fall Educational Conference 2014 SEIPS APIC-Palmetto Fall Educational Conference 2014 For Patient Safety 8 For Patient Safety Person Approach vs. Systems Approach Complex Systems – agents actions are based on internalized rules Instincts, constructs and mental models Internal rules may not be shared, explicit or even logical i.e. the doctor, the nurse, the housekeeper – all have different internalized rules Is there a “shared mental model” for hand hygiene or is it individual, internalized rules? Systems Engineering Initiative SEIPS Systems Engineering Initiative APIC-Palmetto Fall Educational Conference 2014 SEIPS APIC-Palmetto Fall Educational Conference 2014 For Patient Safety For Patient Safety and latent conditions…the What makes healthcare a unique complex “resident pathogens within the system” system, unlike aviation or chemical plant? Latent failures occur when individuals • Bad outcomes affect one person and the make decisions that have unintended family versus bad outcomes can kill consequences in the future. hundreds (aviation) or thousands (chemical or nuclear power) i.e. staffing models that depend on providers to routinely perform clinical duties above and • Therefore the regulatory environments beyond their responsibilities – introducing time and public perceptions (external pressures, fatigue, low moral environment) are different Systems Engineering Initiative SEIPS Systems Engineering Initiative APIC-Palmetto Fall Educational Conference 2014 12 APIC-Palmetto Fall Educational Conference 2014 For Patient Safety SEIPS For Patient Safety 12 2

9/29/2014 Can HFE Help? • As quickly and accurately as you can – Raise your hand and close your eyes when you know HOW MANY results are out of range. Ready….THEN KEEP YOUR EYES CLOSED UNTIL I SAY “OPEN” 13 Systems Engineering Initiative Systems Engineering Initiative SEIPS 13 APIC-Palmetto Fall Educational Conference 2014 SEIPS APIC-Palmetto Fall Educational Conference 2014 For Patient Safety For Patient Safety What was the difference? • The first data presentation was cognitively challenging because you needed to mentally find the lab value, and then interpret whether or not the value was in range. • Each comparison was an opportunity for error. • The second provided what we call a direct perception display to answer the cognitive challenge I posed to you. • Both are typical of types of displays you might encounter every day. Both affected accuracy (quality/safety) and response time (productivity). What was the patient? Systems Engineering Initiative Systems Engineering Initiative SEIPS APIC-Palmetto Fall Educational Conference 2014 SEIPS APIC-Palmetto Fall Educational Conference 2014 For Patient Safety For Patient Safety Overload  Underload Task demands too high, performance deteriorates because of limited resources Task demands too low, performance deteriorates because of boredom and distractibility Systems Engineering Initiative Systems Engineering Initiative SEIPS APIC-Palmetto Fall Educational Conference 2014 APIC-Palmetto Fall Educational Conference 2014 SEIPS For Patient Safety For Patient Safety 3

9/29/2014 Systems Engineering Initiative Systems Engineering Initiative SEIPS SEIPS APIC-Palmetto Fall Educational Conference 2014 For Patient Safety For Patient Safety After *Slides compliments of Lauri Wolf and Brad Evanoff, BJC, St. Louis MO *Slides compliments of Lauri Wolf and Brad Evanoff, BJC, St. Louis MO Systems Engineering Initiative Systems Engineering Initiative SEIPS APIC-Palmetto Fall Educational Conference 2014 SEIPS APIC-Palmetto Fall Educational Conference 2014 21 21 For Patient Safety For Patient Safety Person Capabilities and Limitations Musculo/skeletal • Sensory • Cognitive • Systems Engineering Initiative Systems Engineering Initiative SEIPS APIC-Palmetto Fall Educational Conference 2014 APIC-Palmetto Fall Educational Conference 2014 SEIPS For Patient Safety For Patient Safety 4

9/29/2014 Tasks Physical Environment (studied more than any element of the model) • Content considerations-repetitiveness and Sensory disruptions: make it difficult to carry • meaningfulness out tasks Air quality: too hot, too cold, smells, stuffy • Lack of participation and control • Noise: can increase • • Skill/knowledge required blood pressure, • • Overload and underload negative mood • Housekeeping • • Paced work Fatigue, stress • Systems Engineering Initiative Systems Engineering Initiative SEIPS SEIPS APIC-Palmetto Fall Educational Conference 2014 APIC-Palmetto Fall Educational Conference 2014 For Patient Safety For Patient Safety Technology Design Technology/Tools/Training Controls, displays - Cognitive skills • • Adding technology may be like adding Computers • another team member, but one who does not speak the same language or share New technologies • the same cultural assumptions. (Woods Bar coding; RFID • 1996) Device design • • That may lead to “technology surprises” - eMAR • What is the technology doing now? Why Hand Hygiene Products • is it doing that? What will it do next? 28 Systems Engineering Initiative SEIPS Systems Engineering Initiative APIC-Palmetto Fall Educational Conference 2014 SEIPS APIC-Palmetto Fall Educational Conference 2014 For Patient Safety For Patient Safety Organization - Local Organization - Global • Training, new technology, time for acclimation, work schedules • Federal laws, national guidelines, standards • Pay and benefits - Motivation? • Management and supervision • International guidelines, standards • Employee identification • Accrediting organizations • Corporate structure • Professional organizations • Corporate culture • Organizational support • Job growth Systems Engineering Initiative Systems Engineering Initiative SEIPS SEIPS APIC-Palmetto Fall Educational Conference 2014 APIC-Palmetto Fall Educational Conference 2014 For Patient Safety For Patient Safety 5