University of Dundee School of Medicine

Dr Evridiki (Evie) FioratouLecturer

Medical School Lead for Behavioural & Social Science

Human Factors Workshop, 2G12 Dalhousie, 18.12.2013

Human Factors Science in the Undergraduate Medicine

Curriculum at Dundee

Outline

Teaching Agenda

Progress

Challenges

Strategic Vision

Teaching Agenda

Teaching Agenda

Development of Human Factors Science in the undergraduate medical curriculum

Integration of teaching and research

Critical thinking development

GMC’s Tomorrow’s Doctors (2009) Outcomes To be Addressed by

Human Factors Science Teaching

Ensuring GMC’s Tomorrow’s Doctors (2009) Outcomes

The doctor as a scholar &

scientist

The doctor as a practitioner

The doctor as a professional

Outcomes 1The doctor as a scholar & a scientist

9 Apply psychological principles, method & knowledge to medical practice(a) Explain normal human behaviour at an individual

level

12 Apply scientific method & approaches to medical research(b) Formulate simple relevant research question in … psychosocial science … and design appropriate studies or experiments to address the questions

Outcomes 3 The doctor as a professional

21 Reflect, learn & teach others(c) Continually & systematically reflect on practice …(e) Recognise own personal & professional limits …

22 Learn & work effectively within a multi-professional team(b) Understand the contribution that effective interdisciplinary teamworking makes to the delivery of safe & high-quality care(d) Demonstrate ability to build team capacity & positive working relationships & undertake various team roles …

23 Protect patients & improve care(a) Place patients’ needs & safety at the centre of the care process(b) Deal effectively with uncertainty & change(c) Promote, monitor & maintain health & safety in the clinical setting,

understanding how errors can happen in practice, applying the principles of quality assurance, clinical governance & risk management to medical practice, & understanding responsibilities within the current systems for raising concerns about safety & quality

Human Factors Science: Design & Delivery

EvaluatingImplementingDevelopingPlanning

An interactive and continuously evolving process

Planning I

Agreement on key Human Factors topics for undergraduate medicine*

Clinical colleagues’ needs assessment*

Identification of Human Factors topics within the extant curriculum

Students’ needs assessment Environmental needs assessment SSCs

Planning II

Teaching Delivery Methods Lectures and workshops Individual and Group projects (teaching–research link

is mutually beneficial)

Assessment Tools In line with the Medical School: e.g.,

formative/summative, written reports, verbal presentations, reflective portfolios, as well as integrated assessment within OSCE, DOPS, mini-CEX and CBD

Developing

Define learning outcomes for: whole Human Factors programme, SiP and PiP phases, SSCs

Identify relevant diverse resource materials for the study guides and the teaching sessions

Develop case scenarios from different medical areas with the help of clinical colleagues to instill HF practice and relevance and to ensure seamless integration (cf. TDGs: Patey, Fioratou, Friar, & Flin, 2011: AME)

Develop diverse research opportunities for transfer of learning from the lab to the medical world (cf. Fioratou, Flin & Glavin, 2010: Anaesthesia)

Implementing (albeit fragmentarily at the moment!)

Fundamental Characteristics of Human Factors

It takes a systems approach

It is design driven

It focuses on two closely related outcomes: performance and well-being

Dul et al. (2012; Ergonomics)

Progress

Year 1

Principles BlockSystems thinking[Clinical human factors skills & IPL] Respiratory BlockIntegration of systems thinking and clinical human factors skills GI Block (in preparation)Application of systems thinking and clinical human factors skills

Principles Lecture

Learning Objectives

Define Human Factors Science

Develop an understanding of systems thinking & its applicability

Explain the relevance of Human Factors Science to clinical practice

Human Factors/Ergonomics Definition

Ergonomics (or human factors) is the scientific discipline concerned with the understanding of the interactions among humans and other elements of a system, and the profession that applies theoretical principles, data and methods to design in order to optimize human well being and overall system performance.

~ International Ergonomics Association ~

“… the theoretical and fundamental understanding of human behaviour and performance in purposeful interacting socio-technical systems, and the application of that understanding to design of interactions in the context of real settings”

~ Wilson (2000) ~

Wilson JR. Fundamentals of ergonomics in theory and practice. Applied Ergonomics 2000; 31: 557–67.

Definition – Reinforced

Systems Engineering Initiative for Patient Safety (SEIPS) Model

Carayon P, Hundt AS, Karsh BT, Gurses AP, Alvarado CJ, Smith M, et al. Work system design for patient safety: The SEIPS model. Quality & Safety in Health Care 2006; 15: i50–i58

The Wayne Jowett Case

Identify the SEIPS elements involved in this case

http://www.smd.qmul.ac.uk/risk/videos.html#

“Consultant –

Nurse – Chart”

In Consulta

tion Room

“Pharmacist –

Pharmacist – Chart –Drugs”

In Pharmac

y Departme

nt

“Consultant –

Doctor – Nurses – Receptio

nist”In

Reception Area

“Nurse – Drugs”

In Pharmac

y Storage

“Nurse – Doctor – Registrar – Patient – Drugs – Chart”

In Treatment Room

Interacting SEIPS Elements in the Wayne Jowett Case

SPA

CE

TIME

How do you apply SEIPS Systems Thinking in practice? Recognise that interactions are central to the care you provide within a particular complex sociotechnical system Explore the interactions of different components of the complex sociotechnical system in which you find yourself Acknowledge not only the psychosocial components of your system but also its physical and organisational components and examine how they impact your patient care Embrace complexity & uncertainty

The Old View of human error on what goes wrong

The New View of human error on what goes wrong

Human error is a cause of trouble Human error is a symptom of trouble deeper inside a system

To explain failure, you must seek failures (errors, violations, incompetence, mistakes)

To explain failure, do not try to find where people went wrong

You must find people’s inaccurate assessments, wrong decisions, bad

judgments

Instead, find how people’s assessments and actions made

sense at the time, given the circumstances that surrounded

them

The Old View of human error on how to make it right

The New View of human error on how to make it right

Complex systems are basically safe Complex systems are not basically safe

Unreliable, erratic humans undermine defences, rules and

regulations

Complex systems are trade-offs between multiple irreconcilable goals (e.g. safety and efficiency)

To make systems safer, restrict the human contribution by tighter

procedures, automation, supervision

People have to create safety through practice at all levels of an

organisation

Respiratory Lecture

Learning Objectives

Integrate Human Factors Principles: systems thinking & clinical human factors skills

Explore problem solving in action Develop an understanding of problem

solving theory Explore problem solving in a patient case Develop an appreciation of problem solving

theory applicability to clinical practice

Integrating Systems Thinking & Clinical Human Factors Skills

Managing stress

Coping with fatigue

Situation awareness

Decision making

Communication

Team working

Leadership

Problem Solving in Action

Try to solve the following problem in groups of no more than 3 people. You have 5 minutes!

You are given 4 chains of 3 links each as shown below

It costs £2 to open a link and £3 to close a link

Your goal is to connect all chains, as shown below, at a cost of no more than £15

The Solution to the Cheap Necklace Problem(Silveira, 1971; Fioratou & Cowley, 2009)

Fioratou, E., & Cowley, S. J. (2009). Insightful thinking: cognitive dynamics and material artifacts. Pragmatics & Cognition, 17, 549-72

Systems Thinking in Problem Solving

Problem solving behaviour emerged from the interaction of your team members, your task, your tools, your environment & our organisation

How can we improve the interaction of our system elements to solve the CNP?

Application to clinical practice

The Elaine Bromiley Case

http://www.risky-business.com/talk-89-just-a-routine-operation.html

Working in groups of no more than 3 people, discuss the following for this case:

What System Elements (from SEIPS) can you identify?

What Clinical Human Factors Skills were involved? What problem solving aspects can you identify that

led to the unsuccessful management of this patient?

Linking the Bromiley case to the CNP problem solving performance

In the CNP Knowledge is necessary

but not sufficient for problem solving success

Persevering with the hill-climbing leads to fixation and ultimately to failure to solve the problem

In the Bromiley case Expertise is necessary but

not sufficient for successful case management

Persevering with intubation leads to fixation and ultimately to patient death

Failure to escape fixation by capitalising on cues in the environment

Suggested Actions from an Independent Review (2005)

Obtain and display a set of the latest DAS guidelines in each anaesthetic room

Develop a protocol to ensure that when any emergency event occurs, be it in the anaesthetic room or the operating theatre, there is someone designated to keep full contemporaneous records of the event and to provide an elapsed time prompt.

Ensure an atmosphere of good communication in the operating theatre such that any member of staff feels comfortable to make suggestions on treatment.

Organise a study day on airway management with particular reference to equipment not regularly used and any peculiarities

Strategies to Minimise Cognitive Errors

Develop insight/awareness Provide detailed descriptions and thorough characterizations of known CDRs with multiple clinical examples illustrating their adverse effects on decision making and diagnosis formulation

Consider alternatives Establish forced consideration of alternative possibilities

Heighten metacognition Train for a reflective approach to problem-solving: stepping back from the immediate problem to examine and reflect on the thinking process

Develop cognitive forcing strategies Develop generic and specific strategies to avoid predictable CDRs in particular clinical situations

Provide specific training Identify specific flaws and biases in thinking and provide directed training to overcome them

Decrease reliance on memory Improve the accuracy of judgments through cognitive aids: mnemonics, clinical practice guidelines, algorithms, hand-held computers

Make task easier Provide more information about the specific problem to reduce task difficulty and ambiguity. Make available rapid access to concise, clear, well-organized information

Minimize time pressures Provide adequate time for quality decision making

Improve feedback Provide as rapid and reliable feedback as possible to decision makers so that errors are immediately appreciated, understood, and corrected, resulting in better calibration

Summary

By exploring problem solving in action, we experienced how heuristics may sometimes lead us to fixation and failure to solve simple problems

The applicability of problem solving concepts in clinical practice can help us appreciate the limitations of our cognitive powers and prepare us for future fixation recovery

By exploring problem solving in the Elaine Bromiley case, we experienced how clinical human factors skills may interact with the particular system elements leading to fixation and ultimately to patient harm

We need to start learning and adopting strategies to minimise our cognitive limitations

GI Workshops(in preparation)

Year 2

Dermatology Block

Child & Family Block (in preparation)

Dermatology Online Module

Learning objectives

Understand the complexity of the dermatology consultation from a Human Factors Science approach

Explore the affective component of clinical work and understand the fundamental attribution error

Reflect on your own emotions and develop strategies against potential fundamental attribution error

Child & Family Workshops(in preparation)

Year 4Transition Block 2 Workshops

Learning Objectives

Introduction to Systems Thinking within Human Factors Science

Problem solving in action – introduction to Systems Thinking in the lab & experimental methodology

Real patient cases – application of Systems thinking in healthcare & naturalistic methodology

Evaluating

Feedback from students*

Feedback from clinical teachers

Learn from the feedback and improve the programme accordingly…

Challenges

Integrating Human Factors principles in clinical training and practice

Human Factors information provided before it becomes clinically relevant

Dissonance between the Human Factors & biomedical cultures

Linking with other teaching (e.g., core clinical problems, clinical skills centre, patient journey, clerking)

Inconsistent modelling of Human Factors principles in the clinical setting

My role and development as a non-clinical lecturer…

Solutions?

Human Factors integration throughout the spiral curriculum

Co-ordination with clinical colleagues but also acceptance of individual differences & contextual

issues

Cultural change via leadership

Strategic Vision

To enhance the synergy between Research and Teaching and ensure sustainability

The Dundee Medical Graduate

Core Human Factors Science knowledge & skills (theory & methodology)

Participation and/or leadership in Human Factors projects impacting medical practice & education

Critical thinking in applying Human Factors in their workplace

Continuous professional development in Human Factors at postgraduate level

Strategies for Sustainability (Research & Teaching Initiatives) Local ~ collaborations with the School of Nursing, Institute of Medical Science & Technology; ~ annual student journal publication/website/youtube (Horizon-type) production of HF research and experiences; ~ annual conference/awards/prizes for HF projects; ~ postgraduate supervision; ~ income generation (e.g., NES, HEA, CSO) National ~ e.g., collaborations with other medical

schools, SMERC, CHFG International ~ e.g., collaborations with DHI & DIMS

University of Dundee School of Medicine

e.fioratou@dundee.ac.uk

Thank you!