Human factors in healthcare

“A stitch in time saves nine”,
“More haste! – less speed!”

Many of us will be so familiar with the messages held by such phrases, it would be almost inconceivable to consider a scientific investigation to challenge their validity or measure their impact in a quality improvement exercise. Collectively, they might now be described as ‘common sense’ and worthy of no more attention that a passive acceptance of their usefulness. But by the very fact these phrases arose and have been passed on from generation to generation sends a strong message that they needed to be communicated – that the ‘sense” that they held was not common to all.
    
Safety is a key reason why these messages come back to haunt us. The unexpected incident that could have been prevented through simple rules of thumb will be well known to all of us – whether occurring to us at home in work; or occurring to other people in the news or even the fictional dramas on television. Such incidents can provide harsh reminders of the ‘uncommonness’ of this sense may motivate many professionals in safety-critical industries towards the application of the scientific models or methods. But where a competing number of patient safety management solutions exist that all appear to be ‘common sense’ – why would the choice be for a solution involving ‘human factors’?

The Human Factor
‘Human factors’ is not, as many people perceive, just ‘team-training’ or a sociological exploration of the culture of an organisation. It is not (as may often be associated with human factors’ alternative term ‘ergonomics’) designing comfortable chairs or easy to use pens or mouse-mats. And with this initial misperception of the field’s objectives, the challenges begin. Possibly the title ‘human’ factors signals something familiar and known, and that every ‘human’ believes they have expertise. But there definition of the scientific discipline is quite specific.
    
HFES 2009 states: “Ergonomics (or human factors) 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.”     
    
Human Factors suffers yet another blow when there is the confusion between this and ‘systems thinking’ – to illustrate, I will return yet again to traditional common sense sayings:

“For want of a nail the shoe was lost.
For want of a shoe the horse was lost.
For want of a horse the rider was lost.
For want of a rider the battle was lost.
For want of a battle the kingdom was lost.
And all for the want of a horseshoe nail.”
    
Whilst a common sense reminder of the relevance of systemic failures and their impact on the big picture and consequences, it lacks real consideration or insight of the humans in the equation.
    
Were there influences on those supplying the nails that prevented them from delivering a reliable service? Were there influences on those replacing the shoes so that they could not respond by addressing the issue in a timely fashion? Was there a possibility of redesigning the horseshoes to prevent a drastic failure with the loss of one nail?
    
Ultimately, one key question remains: “Why were those planning and managing the battle so heavily reliant on the role of one rider?” Whilst admittedly a tongue-in-cheek illustration, this is not dissimilar from the range of influences that impact upon the people working within and around the healthcare system.

High expectations
Still, in practice, it is reasonable to question how this analysis of the roles and responsibilities of people would be any different from normal working life – whether clinical, design, management or policy. We may implicitly expect that equipment and workplaces are designed with consideration for human users. We may even expect that the people working in an environment or as part of a professional discipline would have some input into drastic changes impacting on its current or future practice. But these expectations are not significantly different from the same expectations that insist that every patient is treated in a health system that has been designed and managed to reduce the risks of harm to patients and staff – something a patient would expect to be assured. There may a strong belief in the value of these goals and feeling of a moral responsibility to aim for them, but their occurrence in practice may not be as evident throughout the system.
    
From these examples, the obligations to address human factors may be clear - but for chief executives and front-line staff alike, when these obligations compete in priority with all the others; they may easily be lost in a wealth of financial targets, efficiency or more pressing clinical tasks. Without a demonstration of human factors integration within an organisation, it can be difficult for either chief executives or front-line staff to recognise that the extent of the value for all areas can greatly outweigh any initial effort. Few managers would be willing to take this as a leap of fait” without any convincing predictions of a good outcome and so, to jump its first hurdle, the scientific field of human factors must be willing to be scrutinised through the traditional methods of writing a ‘business case’ including specific outcome measures. Part of this effort towards this has fortunately been addressed by the Defence Technology Centres (2006)’s cost-benefit analysis of human factors integration using case studies from a broad range of industries. Together with convincing financial information, their report ends with a comment from the Inquiry into the London Ambulance Service, concerning the Computer-Aided Despatch system that “users were not sufficiently involved in the system’s development” – a poignant reminder of the extent of the difference between what may be considered an expensive and time-consuming ‘luxury’ for some and ‘common sense’ for others.

Safety consequences
A business case is not simply about the up-front cost, neither is it purely based on quantitative targets. In many ways, the range of influence of human factors may make them difficult to measure and scientifically demonstrate. Consider the implications of a standardised drugs chart, designed and implemented in accordance with human factors principles. Whilst this may make each visit to the patient for each healthcare professional safer and more efficient; in terms of measurable economic and safety targets, the time saved would only appear significant when added up for each professional and every patient. And the safety consequences are usually only measured not in terms of profits but in terms of reduced costs. But this would be considering the change implemented only at local level – now consider this concept on a national scale.
    
Firstly, these small time savings and safety improvements would be replicated over a wide area. Secondly, there would be reduced need for induction training. Thirdly, there would be reduced time delays in struggling with “just another new thing” in a new area and reducing the burden on other staff as they stop to point out how their local practice works or correcting the errors on the chart where information has been written wrongly or in the wrong place. Whilst to present a business case for such an idea would be challenging, with benefits such as these, it seems difficult to see any barriers to implementation of such a concept. Yet if design or implementation is done without human factors, even the most beneficial and well-meaning idea can fail. Consider if the chart was designed only with one set of healthcare professionals in mind, or implemented in an area without all the local staff being consulted. Whilst this still appears like common-sense advice to avoid such scenarios, few of us have to resort to reading public inquiries or national news to identify scenarios where this common sense did not emerge.
    
Doubt may still remain in the minds of stakeholders such as chief executives, managers and healthcare providers and these may not prioritise a need for patient safety against financial or efficiency objectives quite as much as a patient would. So if there could be a broad business case for patient safety, patients themselves certainly would be key advocates. But if given a range of solutions, why would patients choose a comprehensive management of ‘human factors’ and not simply the purchase of technology or employing more staff?

Staff roles
Perhaps because for some well-staffed, high technology industries, it may not be for the want of staff or technology that problems arise, but the way the people’s roles and responsibilities are organised within their systems of work. No one would doubt the level of technology or ‘adequacy’ of the numbers of qualified people working in the banking sector – yet still there have still been several undisputed failures within this system. There is often the assumption that technology always enhances human abilities – and it is easy to forget that the human error can pervade even the most complex of systems; through design of technology or management of the human roles that surround it. Put simply, technology can introduce as many new risks as it is perceived it eliminates.
    
Perhaps then the solid rationale for ‘human factors’ is based on knowledge that the occurrence of actual incidents usually results from a catalogue of human errors, and rarely from just one. It is regularly quoted that 80 per cent of incidents are due to human error and it is a common mistake to focus this entirely on the front-line provider. But, when one consider the broader system, it is likely that 100 per cent of these unforeseen events are a result of human error, from throughout an organisation and even beyond it, from the policy-makers, educators, management, procurement, recruitment, IT, designers or manufacturers of devices and more. It may be easy to sometimes forget that each and every one of us is a member of this error-prone human community and pour scorn on the mistakes of others. But should an individual perceive themselves as naturally occurring in some idyllic error-free domain; they would also tragically disassociate themselves from the experiential learning mechanism that provides the solution – the opportunity for human perception of error occurrence; human actions to avoid past errors occurred and actions towards error recovery. The IT system that does not allow human action to reverse the progress of unintended and negative consequences is the stuff of nightmares (indeed, the basis of several horror movies).
    
In a system that is as heavily reliant on human behaviour as healthcare, there is a key necessity is to ensure recognition of human fallibility and the influences, whether from design, environment, policy or culture, that weaken us to a state where the risk of errors becomes high. No field or discipline, other than human factors, integrates the psychology, physiology and systems thinking with this goal entirely in mind. Whilst it may be all too easy to proclaim that healthcare cannot afford to account for human factors; quite simply, it seems it cannot afford to ignore them.

Acknowledgements
Thank you to Bruce Warner of the National Patient Safety Agency for his support in producing this paper.

References

• HFES (2009) Human Factors and Ergonomics Society homepage (accessed 1 Sep 2009 http://www.hfes.org/web/AboutHFES/about.html)
• Defence Technology Centres (2006) Cost Arguments and Evidence for Human Factors Integration. Issue 1. October 2006. HFI DTC.