Design should start with the people we are (part 2)

There is a growing understanding that ‘human factors’ play a huge part in organisational culture, as well as in the system failures that cause harm to patients. 

Many of the problems that regularly turn up in root cause analysis are attributable to the unavoidable and inevitable propensity for humans to make errors. These could be assumptions, complacency, assertion, lapses in judgement, failures in communication, decisions made in haste and without review and basic physiologically induced issues such as stress, fatigue and hunger. Checklists, reminder stickers and improved paperwork have all been used to counterbalance the human factors that can influence clinical work.

Another way of understanding how human factors influence the quality of care is to ask the questions ‘Is it easy to do the right thing?’ and ‘Is it hard to do the wrong thing?’ Poorly designed systems encourage ‘workarounds’; one study into system reliability noted that staff routinely used disposable gloves as tourniquets. These non-standard, temporary fixes identify systems that are not working properly and prevent people from doing their job effectively.

In participating in collaborative programmes within 1000 Lives Plus, clinical teams have displayed considerable ingenuity and creativity in adopting human factors thinking. The use of Patient Status at a Glance (PSAG) boards, Situation Background Assessment Recommendation (SBAR) communication and standardised assessments, and involving the whole team, have led to demonstrable improvements in the reliability of care. The use of the NHS Early Warning Score (NEWS) system to identify patients’ deteriorating health, and ‘stop orders’ to remind staff to remove peripheral venous cannulas or urinary catheters, are good examples of decision aids and reminders.

There should be ‘redundancy’ in processes, so that a failure in one area does not lead to catastrophe but is caught by a secondary (redundant) check. This is important when considering the intensity of work versus downtime, bed occupancy and staffing levels, since compromise in any of these reduces the time available for checks and thus the safety net that might otherwise be in place.

Scheduling is important in achieving high reliability. Success with intentional rounding, where nurses check on patients regularly, has seen improvements in nursing care, particularly in observing patients who are at risk of dehydration or malnutrition. Understanding how people actually work also reveals potential areas for improvement: for example, Transforming Care initiatives rely on an ‘activity follow’ to identify where time is wasted through poor organisation or unclear roles.

As healthcare workers, we need to recognise that we are constrained by our own human limitations; good design can compensate for that and remove the capacity for error that we all have. But implementing people-centred design also helps to counteract the possibility for systems to become impersonal, rigid and uncaring.

The good news is that we can shape our systems around people, and when we do that we can be assured that we are genuinely meeting the needs of the people we care for.

Dr Alan Willson is a director of 1000 Lives Plus, Wales’s national healthcare improvement programme. www.twitter.com/dralanwillson.