Human Factors in Healthcare Blog

You look up over the top of the newspaper you planned to read later.  You see the first sign of trouble:  two agents backing away from the counter whispering to each other.  Yep, it is 10 minutes past “official time”, and that darn door is not propped open.  You could ask the agents, but you know they will not tell you anything unless the delay becomes tragi-comic.  Perhaps not until they are sure you are 30 minutes late.  Sometimes the folks working in back will bypass the frontline agents, so you decide to check other sources of “truth” about how late you might get home.  Hopefully, you have “planned” to be late and do not have critical child care or work tasks.  Suddenly, you feel that hot, Elaine Benes-like, irritation welling up.  PLEASE MOVE!  Or, just tell us when we will all get moving.

Of course I am tricking you!  I am talking about almost any encounter with healthcare settings.  Although my level of irritation at delay last night in Providence did inspire this posting (60 minutes delay, not as bad as 12 hours in Baltimore last year).

There are many human factors engineering lessons about how to address delays when seeing a physician, getting a scan, or other services. 

First, vague concepts like “transparency” or “customer first” are hard to translate into design.  You end up with pictures of people rowing on the wall and signs that say “speak up if no one has talked to you in 30 minutes”.  Instead, think of delays with your computer.  Which helps more:  a) the little rotating symbol that indirectly indicates a web page might be loading; or b) a progress bar and estimate of time for download.

Second, people want clear options with costs and benefits that make sense to their condition.  NOT a good example of options: 1) stick around in earshot of a person you have never met who will yell your name over the top of other noises; 2) leave the area and lose your spot in the queue.  More useful options: 1) stay in earshot to see the surgeon and visit loved one in post-op in seconds; 2) stay within 5 minute walk and carry pager; and 3) give us your email for us to send you the outcome, and see your not-as-much-loved one upon discharge.

Third, situational awareness of those serving and those being served is tricky to do, but everyone benefits.  Do you think that gate agent last night wanted someone screaming at her when we were only 30 minutes late?  Why don’t they have a status light that is

• Green when they have actionable information and are about to tell you,
• Yellow when they have only partial information, and not actionable.  However, yellow is a promise a “green” light within 5 minutes
• Red is when everyone is the dark, and communication and trouble-shooting are broken.  It is always accompanied by a best guess number.  You are free to rebook at a $100 fee; or get a pager and go eat (they will pay if the pager goes off before you eat); or get a $50 certificate and stay in the area.

I know that last set of options would not work, but it tries to get at the idea of all of the key people having the best situational awareness possible.  Your thoughts?

- John

I am going to help organize and judge a patient safety re-design competition this Saturday.  Several groups of nursing, medical, public health, business and engineering students are going to look for known or potential design issues for a dialysis machine.  They will then have a few hours to conceive of and construct 3D models (boxes, paper, etc.).  It is a new competition for University of Michigan, and organized by a really cool student-led group called IHI-Open School.

Whenever I judge such things, my thoughts go in two directions:  what are my lessons learned on BEING A JUDGE?; and what are my lessons learned on BEING JUDGED.

JUDGING 101

Follow the rules.  If the producers of the Food Network show tell you to fill 4 plates of food…fill four plates – not just one to share.  When I was honored to be one of 6 judges of a Texas chili cookoff in Houston, they told me one inviolate rule: NO BEANS IN CHILI.  Sure enough, the 4th team had beans in the chili and the first judge just dumped it onto the ground and asked for the next team’s submission.

Know your audience (judges).  No one is without bias…or, said another way, are they able to forget what they have liked and disliked in the past; or able to forget what they just saw most recently.  During the chili cook-off, I noticed most judges giving 7s and 8s (out of 10) for the nice-tasting series of typical chilis.  When we got a super spicy entry, my spicy palate gave it a “10″, but the Texan next to me gave it a “2″.  I am not saying you should betray your “self”, but you should know that judging is not really fair in the way you would think.

BEING JUDGED 101

Listen to (almost) Everyone.  If your dad says your presentation was “so-so” because you frequently uttered the space filler “uuhhhhh”, you should listen.  If a post-session survey says your co-presenter is wearing a sweater that makes him look like “Mr Rodgers Neighborhood”, then less listening is okay.  (Note: photo courtesy of folks who invited me to present at Northport VA Medical Center…I don’t have a photo of my co-presenter in the sweater.)

Interpreting Constructive Feedback is Tricky.  See advice above…  The judge’s context, recent experience, and set of “rules” might not be all that obvious.  There were mostly positive items in two recent reviews of our book on HFE and Healthcare (Human Factors Society – Healthcare Technical Group; Biomedical Instrumentation & Technology - BIT).  In the case of BIT’s review, the reviewer also provided this critique:  “The authors are too narrow in their description of what constitutes a good HF engineer…”  And, “Many of the most successful HF engineers did not come from pure HFE academic backgrounds…”.  We had to read his critique twice and chapter 4 twice before realizing that our advice was somewhat easy to misinterpret (i.e., reviewer’s perception was correct).  We realized we had not emphasized enough that baseline HFE knowledge and skills could be acquired in many ways…and that experience in applying those concepts and methods were success factors (not necessarily formal degrees).

Judging Strengthens Everyone.  If you have to create a scale to determine the best redesigned device, you will learn.  If you have to make that judgement explicit, you will learn.  If you have to defend it in front of an angry mob of students, you will learn…to bring consolation prizes, like taking everyone for a beer after the competition.

You could find many articles in academia about device safety, usability and human factors engineering (HFE).  From judging the usability of techniques to cool patients after cardiac arrest to assessing insulin pens for the person living with diabetes, there are more and more research reports about applying the HFE technique of usability testing to devices.

What about in the “real world” that most of us live in?  In non-academic resources, it might be a bit harder to detect.  If you search Google for HFE, usability, and medical devices, you can find articles in the medical industry press with increasing frequency.  A pioneer in this area (since at least the 1990s) is Medical Device & Diagnostic Industry (MD&DI).  A very recent article in this trade publication shows the need to HFE in home devices.

In this Blog, we plan to highlight and comment upon HFE and Healthcare in the news.  This can help you in three ways:

1. Support your activities, if you are doing HFE for a living
2. Give you a break from reading our stuff (i.e., other perspectives)
3. Point out to novices the trajectory of thought and work in this area

Have a great weekend…  For many of our USA readers, please enjoy the snow like I will while snowmobiling and skiing in Northern Michigan.