Human Factors in Healthcare Blog

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.

Last Wednesday Laura went in to an ambulatory surgery center for a (hopefully) final procedure for a serious illness.  Besides watching the pre-op phases of her surgeries (N=5), I have seen the pre-op phases of both my children.  Fortunately they are now all doing fine.

Some have called the phases prior to skin cutting similar to the various important steps that need to be accomplished before a plane takes off.  Thus, we have seen this big increase in use of so-called checklists to help ensure somewhat important things like starting on time, to somewhat more important things like getting the right patient and doing the right procedure.

Checklists usually go hand in hand with “double-checks” and other attempts at improving reliability.  Just think about the care you take in prepping to drive to work a few miles on a sunny day versus trekking 600 miles during the dead of winter.  We all know that the checklists work, don’t we?  There seems to be a lot of them for pre-op preparation, so the flow of patient and process must be smooth and with few hiccups, right?

As you might guess, that is not always what I see.  A checklist that is well-agreed upon, crucial task-centric, visible, obviously tied to useful outcomes, and USABLE has a chance of working.  These “animals” are hard to make, usually more expensive, but easier to implement and STAY implemented.  It appears that the lists, checklists, whiteboards, and other documents are nice beginnings – with work to be done.

Here is one example in the literature where using HFE principles moved the usage rate by doctors from ~10% to ~75%.  Even the authors could not believe paying attention to seemingly minor details made such a huge difference.  Getting the “paperwork” right will save more time and prevent more injury than you think…