Quality Education for a Healthier Scotland
Multidisciplinary
Making it easier to do the right thing
Michelle ClarkTraining and Research Officer
(Health Psychology)NHS Education for Scotland
Mark JohnstonTraining and Research Officer
(Patient Safety)NHS Education for Scotland
[email protected] 656 3258
Workspace
Culture
Organisation
TaskTeamwork
Impact on behaviours and abilitiesAdapted from Catchpole
@markjohnston71
Quality Education for a Healthier Scotland
Multidisciplinary
Human Factors case study – Hand hygiene behaviours of final year
medical students
Quality Education for a Healthier Scotland
Multidisciplinary
Pilot study – what we did
• Final year medical students at University ofDundee Medical School
• Mixed methodology
Quantitative (n=30)
Questionnaire assessing
• Predictors of HH behaviour
•Barriers & levers to HH behaviour
Qualitative (n=9)
Based on students’ final year ‘ward simulation exercise’
assessment video
‘Self-explanatory’ interview
Categorical content analysis using HF & Health Psychology
theory frameworks.
Quality Education for a Healthier Scotland
Multidisciplinary
Results – Questionnaire Predictors of behaviour
Attitudes
Normative beliefs
Perceived behavioural
control
Behaviour intentions
Behaviour
Theory of Planned Behaviour (Ajzen & Fishbein, 1980)
Quality Education for a Healthier Scotland
Multidisciplinary
Results – QuantitativeBarriers & Levers
(Theoretical Domains Framework (TDF) Michie et al 2008)
• The higher the number of barriers, the less HH behaviour is carried out
• Compared TDF domains based on levels of compliance (high or low)
Knowled
ge &
skills
Profes
siona
l Role
Beliefs
abou
t Cap
abilit
ies
Beliefs
abou
t Con
sequ
ence
s
Motiva
tion &
Goa
ls
Memory
& A
ttenti
on
Enviro
nmen
t
Social
Influ
ence
Emotion
Action
Plan
s02468
101214161820
Low ComplianceHigh Compliance
** **Mean
scores
Quality Education for a Healthier Scotland
Multidisciplinary
Results – Qualitative‘Self-explanatory’ interview
Observable HH behaviour low (despite high self reported HH)
Individual factors
Positive impact• Attitudes & beliefs (capabilities & consequences of HH)•Motivation
Negative impact•Stress & anxiety•Human cognition & memory (mental load, dual processing, primacy effects
Task related factors
Negative ImpactMultiple tasks•Switching between multiple patients•Changing symptom presentation•Problem solving nature of tasks
Environment factors
Positive Impact•Multiple gel bottles •Prominent location
Negative Impact•Layout of ward•Layout of paperwork/forms.
Quality Education for a Healthier Scotland
Multidisciplinary
HH Pilot study (cautious) conclusions• Clear intention-behaviour gap (self report & observed HH
behaviour)
• Cognitive factors & beliefs about capabilities are barriers to HH (in this group)• Making several decisions within a high pressure
situation lead to high cognitive load which negatively affects memory – automaticity not achieved
• Need to believe you are capable of performing HH
• Attitudes towards HH & Social influence (especially from influential staff members) can predict HH behaviour
• Primacy effect evident in practice of WHO 5 moments, but not recency effect (forgot moments 4&5).
Quality Education for a Healthier Scotland
Multidisciplinary
Implications...
Teaching of Hand Hygiene behaviour
• Impact of stress/anxiety and cognitive load on HH behaviour & make behaviour automatic even in stressful situations
• Other prompts to remind & encourage habits at more of the WHO moments.
Quality Education for a Healthier Scotland
Multidisciplinary
Bad people?
Error occurs due to Systemic and Systemic induced Individual failure
Negligence is not the same as error, both may result in harm
So, some thoughts on why…?
Quality Education for a Healthier Scotland
Multidisciplinary
105 HF facilitators workshop Sept 11
Quality Education for a Healthier Scotland
MultidisciplinaryYou’re amazing!
Quality Education for a Healthier Scotland
MultidisciplinaryWhy do we make mistakes?
• Sometimes we do the wrong thing, consciously and sub-consciously
Quality Education for a Healthier Scotland
Multidisciplinary
Quality Education for a Healthier Scotland
Multidisciplinary
<1% 5% 50% 80% 100% percent of driversPERFORMANCE
Indi
vidu
al A
uton
omy
The posted speed limit is 60 mph- the ‘legal’ space
Driving 64 mph-the illegal-
normal space
Driving75 mph – the ‘illegal-illegal’ space (for almost all of us!)
VE
RY
UN
SAFE
SPA
CE
IndividualPressures
PerceivedVulnerability
Belief inSystems-guidelines
Accident
Driving 100 mphillegal for all Borderline Tolerated
Conditions of Use
Adapted from Rene Amalberti
Normalisation of Deviance
Quality Education for a Healthier Scotland
Multidisciplinary
Even experts make mistakes
Quality Education for a Healthier Scotland
Multidisciplinary
Human FactorsA common language
“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 2010)
“Making it easy to do the right thing” (Bromiley 2011)
Organisational/ Management-Safety Culture
-Managers’ Leadership-Organisation communication
Work/Environment-Work environment
and hazards(ergonomics)
Workgroup/Team-Teamwork
structures & processes-Team Leadership
Individual Worker-Cognitive skills
• Situation awareness• Decision making- Personal resources
• Management of stress• Management of fatigue
(Flin, Patey 2012)
Quality Education for a Healthier Scotland
Multidisciplinary
The first lesson in reducing harm is the realisation that we will and do make mistakes
‘It’s the downside of having a brain!’
Reason
Quality Education for a Healthier Scotland
Multidisciplinary
Multi-tasking - Our lazy brains would rather default to system 1
2 x 2=
17 x 379 =
4…System 1
6443…System 2.
Kahneman 2012
Quality Education for a Healthier Scotland
Multidisciplinary
Card suit change game
Groups of three
• 1 Person deals cards, turning them face up in rapid succession and estimates the passing of timeIf you deal all the cards deal them again
• 1 person estimates the passing of time with no aid and counts the number of times the cards change suit.
• 1 person times the activity using an aid and then focuses only on recording the suit changes
When told to finish, separately record the time and number of suit changes and compare your results
Quality Education for a Healthier Scotland
Multidisciplinary
Where can we start?
“Making it easy to do the right thing” (Bromiley 2011)
(Flin, Patey 2012)
Work/Environment-Work environment
and hazards(ergonomics)
Quality Education for a Healthier Scotland
Multidisciplinary
‘We cannot change the condition of those who do the work, but we can change the conditions within which they work’
Reason J. BMJ. 2000 March 18; 320(7237): 768–770.
Quality Education for a Healthier Scotland
MultidisciplinaryEveryone, everywhere, every time
Good human factors design in health care accommodates everyone
Not just the calm, rested experienced healthcare worker
But also the inexperienced health-care worker whomight be stressed, fatigued and rushing.
Quality Education for a Healthier Scotland
Multidisciplinary
Quality Education for a Healthier Scotland
Multidisciplinary
Where can we start?
“Making it easy to do the right thing” (Bromiley 2011)
Organisational/ Management
-Safety Culture-Managers’ Leadership
-Organisation communication
(Flin, Patey 2012)
Quality Education for a Healthier Scotland
Multidisciplinary
‘We cannot change the condition of those who do the work, but we can change the culture within which they work’
Quality Education for a Healthier Scotland
Multidisciplinary
Silo working?
Doctors
Managers
Nurses
What is your culture?
Quality Education for a Healthier Scotland
Multidisciplinary
Hierarchies?
Quality Education for a Healthier Scotland
Multidisciplinary
Do we pay attention to the Swiss cheese or do we blame?
Our learned behaviour is to blame an individual
Society, peers, media
Imperfect System
Our colleagues, ourselves?
Quality Education for a Healthier Scotland
Multidisciplinary
Where can we start?
“Making it easy to do the right thing” (Bromiley 2011)
(Flin, Patey 2012)
Workgroup/Team-Teamwork
-Team Leadership
Quality Education for a Healthier Scotland
Multidisciplinary
Lessons for Leadership inchanging culture
Culture change and continual improvement come from what leaders do, through their commitment, encouragement, compassion and modelling of appropriate behaviours.
Berwick Report 2013
Quality Education for a Healthier Scotland
Multidisciplinary
Where can we start?
“Making it easy to do the right thing” (Bromiley 2011)
(Flin, Patey 2012)
Workgroup/Team
Structures & processes
Quality Education for a Healthier Scotland
MultidisciplinaryExamples in healthcare…
• Prescribing and dispensing
• Hand-over/hand-off information
• Movement of patients
• Order of tests
• Preparation of medication
• If all of the processes associated with these tasks make sense and become easier for the ‘human’ to comply with, then patient safety will improve.
Quality Education for a Healthier Scotland
Multidisciplinary
Making it easier to do the right thingPDSA example: Christopher
Christopher to urinate into the toilet bowl 100% of the time by 30th June 2010.
Aim:
Toilet training
Quality Education for a Healthier Scotland
Multidisciplinary
PDSA templateDescribe your first (or next) test of change:
Person responsible
When to be done
Where tobe done
Demonstrate the correct way to urinate into the bowl and indicate the negative aspects of missing the bowl
Me tonight Downstairs toilet
List the tasks needed to set up this test of change
Person responsible
When to be done
Where to be done
Christopher available Me tonight
Downstairs WC
Predict what will happen when the test is carried out
What will determine if prediction succeeds
Christopher will show understanding of process and execute correctly
The floor will be dry
Quality Education for a Healthier Scotland
Multidisciplinary
Example: DSADoChristopher thought the demonstration amusing and ignored it
Study0% compliance with the new process0% reliability level
ActSeek out ideas, develop new test cycle.
Quality Education for a Healthier Scotland
Multidisciplinary
Example: next PDSA cycle
http://www.amazon.co.uk/toilet-training-target-stickers-Happeedays/dp/B002GZAWUK/ref=pd_sim_by_3
A Human Factors approach!
Quality Education for a Healthier Scotland
Multidisciplinary
Making it easier to do the right thing
Michelle ClarkTraining and Research Officer
(Health Psychology)NHS Education for Scotland
Mark JohnstonTraining and Research Officer
(Patient Safety)NHS Education for Scotland
[email protected] 656 3258
Workspace
Culture
Organisation
TaskTeamwork
Impact on behaviours and abilitiesAdapted from Catchpole
@markjohnston71