Human Factors in Healthcare Blog

In my last two postings, I provided some non-traditional advice about how to hire someone for a human factors engineering and design/safety job.  A reminder of the five jobs that contained attributes helpful for an HFE and Medicine specialist:

1. Bartender
2. Bean-packing plant safety manager
3. Lifeguard
4. Set designer
5. Wilderness survival expert

The #3 job, lifeguard, is easy for me to relate to;  I was a lifeguard at a quarry lake for 2.5 summers.  During my time there, two people drowned at this lake – both times I happened to be off.  Nevertheless, we “pulled” many kids and adults out of situations where they were drowning or near drowning (N=30-40 per summer).  It was an old, deep quarry that was very crowded and full of many people who could barely swim – but tried anyway.

What does this have to do with skills and knowledge to be a HFE and device/healthcare expert? 

It all starts with the training.  Nearly 30% of lifeguard training is learning how to use “judo” moves to escape the clutches of a frantic, grab-at-anything drowning person.  This frenzy is not nearly the same as designers and engineers whose prototype is “drowning”, but there are parallels.  We learned some of this at a how-to-be-a-consultant workshop I took at Usability Professional Association (UPA).  The “master” consultant went through several resistance strategies we would encounter from product designers who felt threatened – and how to “wrestle” our way out of their “clutches”.

Secondly, drowning or near-drowning does not look like what you see on TV.  Major human factors engineering design flaws are often not what you think (or just common sense).  There is very little splashing and waving.   Major HFE design flaws are often subtle or hide.  In both cases, you not only need to train yourself about these counterintuitive ways of monitoring the situation, you need to be able to teach others. 

Third, lifeguards very quickly learn that their job is a lot of being tested, being drilled, and regular practice.  Hands-on, lots of feedback, peer input, and building a thick skin.  Its not boot camp or military, but often close.  Applying HFE in the hectic healthcare or device development arena requires you have that thick skin.  You also need to develop it in your design, marketing, engineering, and management colleagues.  HFE is about high contact, hands-on, and lots and lots of testing.  Building thick skin requires repetition, tack yes, but repetition.

Next, we look at  the job of “set designer” (huh?!)

In my last posting, I began a thread about how to hire someone for a human factors engineering and design/safety job.  These were the five jobs that contained attributes helpful for an HFE and Medicine specialist:

1. Bartender
2. Bean-packing plant safety manager
3. Lifeguard
4. Set designer
5. Wilderness survival expert

In his many years at a green bean packing plant, my uncle had a large role in worker safety.  Sure, there were some efforts that were typical (XX days since finger has been sliced off), and some that went askew (200 winter coats emblazoned with the misspelled slogan “Saftey First!”  However, many efforts involved involvement…  No, that’s not double talk.

It means that  they closed the plant down one or more days per year and everyone in the plant met to talk about injuries and ways to prevent them.  Everyone, meant that they hired temps to cover reception.  The supervisors had the job of safety and had to weave the lessons they learned in these “retreats”…it meant they needed skills and patience to translate the lessons into concrete actions and expectation.  It meant they needed to be flexible enough to weave stories of caution with verbal “kicks in the butt” to keep summer workers from loafing.  Knowing the goal of the plant is clean, tasty food that is packed quickly and as efficiently as possible…and knowing that one finger tip that a consumer finds in a can will be on the nightly news for 9 weeks (maybe even a “60 Minutes” Special!).

Humor surely helps.  Softening the harshness of zero tolerance for not wearing hard hats is an art.  A person needs good timing of when to tell the story of the temp worker who was nearly boiled when they bypassed the safety system  Knowing when to get real and when to be one of the gang is a balancing act. 

All of these seemingly “natural” skills aren’t.  If you find an HFE & Medicine candidate who has some or most of them, HIRE THEM ON THE SPOT.

Next Posting:  Lifeguard skills – how to disarm a drowning man!

New software may require subscribers to actively pick all the categories – or they don’t get email notices of new postings (sigh!).

Years ago, the most common question I got was, “where do I go to learn more about human factors engineering?”  The the length and breadth of my answer did evolve as more workshops and books (including our own) came on the scene.  Funny, very few people thought it was funny when I said that they could go back to school and get a masters degree in HFE in just a few short years!  I was only partially kidding, since I knew that some of the design or safety questions they would tackle could easily be major essay questions on graduate level tests – or even research theses.

Many people now ask different questions:  who should I hire?  where can I find them?  [These are harder questions, so I reminisce about the old days of the easier questions above.]  The question arises frequently enough, that we devoted part of a chapter in our recent book to this.

Simply stated, it is only a small problem to find people with masters degrees or PhDs in human factors engineering.  That is not enough.  They need one or more other qualities.  Below, and in the next 4 postings, I will describe and give examples of some of those needed qualities for an HFE and Medicine specialist:

1. Bartender
2. Bean-packing plant safety manager
3. Lifeguard
4. Set designer
5. Wilderness survival expert

Skills of a bartender (or, if you will, ombudsman) are key!  Your HFE will need to be able to listen, and listen, and listen.  Those 40 minutes of seemingly irrelevant stories are the needed lead-in for a patient to reveal the real problem they have with the device or medication delivery system.  The HFE needs to be trusted by the usability test participant clinicians when they see “interesting” usage of devices or medications.  They should have a ready supply of (NON-ALCOHOLIC) drinks and other pleasantries to set the stage for stressful design meetings.  Sometimes, especially during “last call”, they need to summon jaw-dropping honesty about bad things that might happen if the product goes “out” - and be willing to stand up to peer pressure.  Finally, be prepared to help out with lots of jobs, clean up messes, and know how to fix things on “the fly”.

In no particular order, here is what I learned this summer:

1. All cars sold to haul kids on vacation trips should have “glass wall” options like taxis to close off the back seat noise and shrapnel
2. If someone says they are car sick, it is better to stop and spend 5 minutes for a short walk than to clean vomit for 15 minutes
3. GPS systems can be wrong…really, really wrong:  “turn left onto the (non-existent) ferry”
4. Seemingly small wayfinding and other design flaws in hospitals can grow large when your friend or brother are sick
5. Medical residents are getting more and more savvy about patient safety (this is a good thing)
6. Medical residents are impatient with progress in patient safety (this is a great thing)
7. You can say you are going to write blog posts every week, then life happens

For those (still) reading my posts, I am going to upgrade the system to make sure you get announcements of my new posts.  For those about to read my posts, I am going to improve my marketing and networking to inspire me to continue my posts more regularly.

Last week my dad found and read the print-out of my first 12 Blog postings.  He was very interested, and we talked about the useful nature of the Blog.  He thought it could have a wide audience and most postings were readable.  I had given him the print-out weeks ago, but until recently it was lost in a pile of other papers and items that are stacked 3 feet high near his TV chair.  He does not have a computer – so he had to read the paper version.  He is not computer-phobic, since he actually had used computers in his high-school class since the early 1970s (yes, 1970s).

My dad has been an indirect and direct inspiration to my work.  In 1998, I wrote an editorial to British Medical Journal about human factors engineering aspects of physician communication.  I wanted to humanize the editorial (critique) for this popular medical journal, but also push the concepts and methods of the underappreciated HFE.  So, I told the story of a miscommunication of a echocardiogram (ultrasound of the heart).

In 1997, a nurse had told my dad that the “Echo” report said that he had aortic stenosis, and needed to be seen by a cardiologist.  He told me later, and I was stunned because symptomatic aortic stenosis has a very poor outlook.  I happened to be traveling to Northern Wisconsin that next week and was anxious to learn more about any further testing and the plan (e.g., surgery?).  When I arrived and talked to my dad, he told me the nurse called back and said, “never mind, we got the report wrong, you only have minor changes of atherosclerosis!”  This is a fairly common finding for this age, and often not a big deal.  Since the mistake went in the good direction for my dad, we all laughed about it.

Years later, I was to find that there is a whole host of look-alike and sound-alike terms that get messed up during dictation, transcription, verbally communicating, etc.  Medication names are the most infamous.  In 1990, several journals described fatal confusion between lasix and losec.  This resulted in the drug name of losec changing to prilosec.  ISMP, FDA, and other medication safety organizations have devoted much time and energy to prevent as much of this as possible.

But most safety people find out quickly that we humans do not really “read” in the same manner as a computer scans a document.  We do not synthesize stuff in our head the way a computer program does.  Humans are great at grabbing fragments of the familiar, making a best guess, and acting quickly.  Star Trek the Next Generation and other SciFi shows have used our unique power of good guessing in their ”man wins out over cyborg” episodes.

But some “tricky situations” require us to switch from using inference and hunches and go to a more step-by-step approach.  But the problem is realizing when we are in these “tricky situations”.  How do we know when to slow down.  Worse yet, if they are REALLY tricky, like watching a magic show, our step-by-step approach will still fail us.  Magicians Penn and Teller have actually helped write and present at professional conferences about some of this linkage between magic and cognitive science.

The goal of human factors engineering is to find out where we have accidentally added “trickiness” to our devices or systems.  And we really want to find out if we have made our design so tricky that a magician would be proud.

A few weeks ago I was teaching about human factors engineering to a group of hospitalists at the Society for Hospital Medicine meeting.  Many of the hospitalists (physicians focused on delivering care mostly in hospitals) in the audience had a minor or major role in making things safer in thier organization.  Some had no idea about human factors engineering, or had heard it described as the study of factors that make us flawed humans. 

Personally, I like my former co-worker’s definition that focuses on ergonomics.  Since his early days at NASA was around engineers building new crew capsules, he defined human factors engineers as ”the group of people who measure people’s butt cheeks to design the seat so it fits!”

I have tried many methods to introduce HFE to novices, but the two main methods are interactive exercises and demonstrations that put people in position of seeing things that were previously underappreciated.  An exercise I tried for the first time at the SHM meeting was to have two groups of 2 people try to find the location of an AED.  The scenario was that I suffered a heart attack and they had called 911 and were pursuing an AED that they believed was mounted on the wall somewhere in the hotel conference center. [previously, I have written about signage for AEDs].

On each team, one person was assigned to find the AED and think aloud about their plan and other thoughts.  The other person was to record those words and actions – especially where the searcher was looking and resources they sought to find the AED.  The room had exits to different hallways for each team to began searching. 

In short, one person immediately asked hotel personnel, who did not know.  Then they asked conference information desk, who pointed across the middle, large hallway to the easily visible AED sign and wall storage unit.  The other person just had instincts to look centrally in the 400 foot main hallway, and was correct.  Neither used their smart phone, their map included in the conference agenda book, or other tools you might consider if not in a hurry – or, where they in a conference room answering questions in a laid back inteview.  There are a few studies on so-called wayfinding for designing hallway signs, but I have not seen any for searching and finding AEDs?  Do any of you know of some?

Interestingly, when someone did look at the hotel map, it provided locations of three things (besides room numbers-names):

1. Bathrooms
2. ATMs
3. Where you were allowed to smoke

In debriefing the two physicians who were frantically looking for the AED, they did provide one CAUTION to me about doing this exercise again:  make sure the people looking for the AED tell the information desk or other personnel that it is an EXERCISE, and no need to call 911!

I just started hearing that stupid brake squeal from the front of my 10-year old truck…again! The new brake components installed a few months ago were to replace the new brake components installed a few months before that.  I suppose I will have to go BACK IN in order to sell this pretty nice looking, but pig-sounding, truck.

Returning your human body back to the hospital is probably even more irritating.  Did “they” do something wrong? Did you?  Did both? We might decide the “bounce-back” is no one’s problem.  This might be the nicey-nice route, but now there is no incentive on your part or their part to do anything different (i.e., it will happen again).

Reducing readmissions is a key part of health reform and many quality efforts.  Bob Wachter (of Wachter’s World), has a pretty clear discussion of this at his Blog.

Question:  Can we reduce discharge “bounce-backs” with huge computer systems, 85 million pseudo-checklists, and a pile of brussel sprouts (think sulphury tasting carrots)?  I am not sure…

My wife has been discharged from same day and overnight hospital stays many times in the past few years.  What did the healthcare staff do to keep the complications from medical procedures and strong medications from pushing her back into the hospital?  I will save that for her to describe in specific detail another day.

Overall, however, the main tools to tell us how to avoid “bounce-back” were verbal instructions (doc), verbal instructions (nurse), written instructions (standard-printed), written instructions (hand-written), and whatever was printed on the medical items (bandages) or meds we were given.  Oh, and whatever was left over in my head from medical school-residency 25 years ago; and whatever she might have read on consumer or medical web sites or medical journals.  Lastly, in some cases we would get informal consult or input from my medical pals.

Depending on how you want to count, that is 8 or 9 sources!!!  I can hear some of you readers saying, “go with what the doctor says, and downplay the others”.  Some might advise, “go with the handwritten, it is the most customized to your situation”.   Others will recommend, “consumer web sites have the gold nuggets from real patient experiences and tips.  Those doctors and nurses have never REALLY experienced XYZ disease, what do they know.”

Tools (computer or otherwise) need to help streamline or sort this out in a more understandable, easy to use way.  What do I mean by easy to use?  You need usability testing by patients and their caregivers — most realistically when they are sleep deprived, scared, in pain, etc.  Not a simple task to do this usability testing, but CRITICAL to success.

You know that area of your house outside where the phone, electric, gas, etc come into the house (basement)?  Well, do NOT try to use your weed whacker to clear out weeds.  The weed whacker might have problems cutting tall or wet grass, but it chews right through the outer coating of your phone line.  It’s actually a delicate “chewing”, since it just exposes the copper wire to the rain and snow, so that the phone failure takes 4.75 months to happen.  By that time, you have forgotten that you meant to call to have the gnarled up wiring fixed in a routine, non-emergent fashion.

Do any of you know what happens when you call to get phone service fixed?  Yep, it is very much like trying to get an urgent (but not emergent) medical condition addressed by the primary care doctor you have not seen in 6 years.  You go through voice prompt systems, type in you phone or medical number 50 times, and finally talk to someone who tells you that someone else will call you back about the plan…  All that seems understandable, since these customer service people need to be efficient with their time and that of the professionals that they protect, er, help manage finite resources.  You realize the problem, though, when the first person can’t tell you who the second person is, or how to call that person if they don’t call.  Worse yet, you miss their call and you go the “back of the line”, even though you have given them every cell and land line number you own.

Like delayed flights in the last blog post, human factors engineering analysis can give us some clues about design features to improve timeliness of care (or return to phone service).

1) Offer the same ability to track your process as Fed Ex gives you to track your $29 vase of roses.

2) At the risk of being a broken record:  offer clear alternatives to give choice to fit a person’s need.  Offer a phone message every 4 hours, or text, or email…  Or, give a direct number to call if they have not called in X amount of time.

3) Offer up a web page form so you can enter the key details about your medical condition (or phone disaster).  I see why this is avoided, since clinics worry they would be liable for reacting slowly to ominous symptoms.  Okay, but there needs to be a better method than verbally, and less systematically, having someone go over the same story.  Think of this as trying to design stuff to create the best shared model about what is going on, and what should we do next.