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

My son decided to stress test his parents with 60% body rash last Saturday.  We keep a pretty “clean” and food consistent house due to our daughters allergies to 9 food ingredients (from peanuts to poppy seeds!).  So, we could not figure out the rash and were worried it could “spread” to his respiratory system (this has happened with our daughter).  On Sunday, 5AM, his rash worsened and moved into his eyelid area and mouth.

Every time I visit the emergency room with a family member, I cannot dismiss the fact I know that colleagues of mine study the relative design chaos that “lives here”.  Plus, sifting out the bad illnesses from horrible illnesses from run-of-the-mill illnesses is not that easy.  Missing diagnosis is a common reliability issue with super experts, much less someone half asleep and over-worked.

In short, after six physicians in three settings across 2 days saw my son with 40-60% body and facial rash, we took prednisilone and Benadryl until he was bouncing off the walls!  Even though the medications did not seem to work at first, in a few days he was back to his normal bouncing-off-the-walls self, with no rash.

The hardest thing for my wife and I was keeping track of the medication and dosing.  6.25 ml of Prednisilone…really?   10 mL Benadryl as every 6 hours, 5mL Ranitidine as every 8 hours, and 6.25 (then 5mL) Prednisilone as every 12 hours (or twice a day).  Oh, and sometimes we forgot one and then gave it, but 2 hours off cycle.  Needless to say, we used paper medication records to keep track and still messed up (double doses and missed doses).  Anyone who can figure out how to design a way out of this design mess, in a robust, usable, and well-accepted by physicians, will be a billionaire!

Oh, yeah, the markings on the picture of that medication measuring cup are kind of hard to see.  REALLY exciting at 2AM!

I have been invited, forced into, and willingly sought to be on various committees that create “standards”. 

[ASIDE: For those who don't know or work with "standards", I still think you will find discussion about this topic vaguely interesting.]

In one case, I have worked for days in windowless conference rooms with barely a break.  In another case, I have spent minutes giving my input (testimony) in the hallowed halls of Institute of Medicine.  Never, repeat, never is any of work done in tropical resort hotels like the one depicted on the right.  Sometimes our end-point is clear, but often it’s not.  Example of clear end-point:  create a list of the minimum processes/steps needed to validate a better medication warning label.  Example of less clear end-point: create a summary of all patient safety remedies that are effective, or can be made effective, or have hints that they might be effective (yikes!).

In the 2000’s, I was part of the Association for Advancement of Medical Instrumentation’s Human Factors Engineering Standards committee.  We were assembling a second document (HE-75) to complement the first standard (HE-74).  [Aside #2:  most standards are somewhat costly, but I do not receive any $].  The standard has been in both the medical device and human factors engineering press lately.  A recent webinar was held by co-chair, Ed Israelski, for HFES.  And MD&DI (trade pub) has had nice explanatory pieces.  It is stated that FDA and possibly other stakeholders will take special note of the guidance and standards contained in HE-75.

Is this good?  Does a standard or guidance help to standardize or guide design?  To answer those questions, let me ask a rhetorical question:  when has a standard or guideline helped you do your job? 

My guess is that an effective guideline reminded you what to do, and the context in which you were supposed to do that thing.  It’s a reminder in that you already knew the guidance, or at least knew that the knowledge existed.  The guideline is centered around what to do, or not do.  It is not suggestions on how to feel, or hints about what thoughts or concepts to consider.  Most important the standard provides the context so you know when to act on this purported wisdom.

Some John-Created Examples

GUIDELINE:  Medical devices that will be used in the home shall be designed to be used by novices 95% of the time

NOT GUIDELINE:  Consider the fact that the user of a device may prefer a range of colors depending on many factors.

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…

Last Saturday I emceed and judged a design competition that was organized by an interprofessional student group called Institute for Healthcare Improvement – Open School (IHI-OS) Michigan Chapter.  Five teams of 4-5 students had watched the hemodialysis device in use, interviewed operators, and read about the pros and cons of having people living with kidney failure use this in their home.  Yes, attach their veins and arteries to a blood-pumping and blood-filtering machine for several hours, 3-4 times per week…

The rules of the competition (criteria for judging) were deceptively simple: clearly identify some design-related problems; suggest and prototype a solution, and make it innovative and user-centered.  Get your medical student, public health student, engineering student, and business student team members to do all that in 105 minutes and you win invaluable prizes (glory, fame, Sears gift card!).

I will leave the details of the event to the student group’s Blog.  For my part the 3 hours on a Saturday afternoon was some of the most fun and engaging in a long time.  Sure, I use design exercises when teaching students or educating engineers about HFE and safety.  But, to actually have the groups do 90% of the work without my help or others — and come up with 5 or 6 breakthrough ideas was really cool. 

Lots of people write about the necessity and wonderfulness of multi-professional teams.  Sounds good…but, it’s often a hassle to create and manage these teams.  Device companies AND hospitals have some mixed teams, but they also have lots of homogenous departments (e.g., biomedical, pharmacy, accounting, etc.).  On this day, and for this application, the mixed mental models seemed to cook up some nice designs.  Concrete ideas to address the solitude, scariness, or tedium of having your arterial system mated with a plastic and metal machine for hours.  Cleverness about giving more mobility and efficiency to the person living with kidney failure, as well as the partner who is sharing the triumphs and set-backs of longer term care situations.

If I suffer a steak-induced illness, I want these teams looking into addressing my cardiac, football-watching, and kid-scolding needs.

- 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.

In the past two weeks, I was honered to be invited to two healthcare conferences to talk about human factors engineering (HFE) and patient safety.  The locations and organizations were quite different, but the content I provided was nearly the same.  In New Orleans, I was on a patient safety panel with Bob Wears at the International Meeting on Simulation in Healthcare.  In Toronto, I was a presenter at the Canadian Society of Hospital Pharmacists (my slides can be viewed on their web site).

I was able to fly home from New Orleans before the big East Coast Storm…  But, I had to stay an extra day in Toronto to wait for the 6-12 inches of Midwestern snow storm to be plowed.  In New Orleans, I re-learned that I like the sound of the word “Gumbo” more than the taste. In Toronto, I learned that the goat in Jamaican “Goat Roti” tastes just like you would think that goat tastes! 

The other common theme besides interesting food was the questions about HFE.  In fact, these difficult-to-answer questions are common enough that I expect them and have written about them:

1. How can we use these ideas and tools in our job settings?
2. Where do we start?
3. Can we do this ourselves, or is it worth it to hire someone?

Q:  How do we use these ideas/tools?  A: The main targets I tell them about fall into two categories:  a) fix the stuff you are stuck with; and b) don’t buy stuff that you will need to fix.  This answer sits pretty well with most folks.  They see the training, re-training, post-market modifications, work-arounds, and other marginal attempts to deal with devices and tools that are hard to use or error-prone.  They want more systematic ways to find and address HFE flaws in the stuff they are stuck with.

They know, in general, that they should not buy stuff that needs to be fixed, but the pathway to do this is much murkier.  Shouldn’t FDA do this for us?  Shouldn’t our biomedical engineers know?  Why would someone build a widget with known HFE issues in the first place?  This is right about the time that I say, “does anyone have any easier questions!?”

Q: Where to get started?  A: there are many places to get started.  Laura and I get this question enough times that we came up with a list of nine ways to get started, and put the list in our new book…  Then, we thought we could expand on the list, and wrote an article for a HFE special issue of Biomedical Intrumentation and Technology.  In future Blogs, you will see excerpts from this list pop up.

Q: Do this oursevles?  Hire someone?  A: “Yes”, is the short answer.  The much longer answer is in our book we recently wrote and edited.  It contains 6 stories (case studies) from around the US and Canada about hospitals that are doing it themselves or had hired HFEs.  The book has recently been reviewed in a couple of venues, and we will make comment in the next Blog entry.

It happened 5 years ago, but I am always reminded of it when I board a plane.  The PA announcement on my return flight from a conference in Las Vegas was something like this: “there is a medical emergency.  Is there any medical people to help us in the back of the plane?”  I was towards the front of the plane and looked back to see no one standing up.  I reluctantly went to the back to find a semi-conscious middle-aged man and two flight attendants who looked worried.  I had not practiced medicine in 15 years, but had some recurring training and exposure to emergency care.  When we removed the in-flight med kit, we found bandages, aspirin, a small EKG machine, and little else.  I wanted an AED (automated external defibrillator), but none was aboard.  Long story short, I assessed him, spoke by teletype to medical consultants at Mayo Clinic, the plane kept flying, and he eventually did okay and left the plane under his own power.

Because of this encounter, and HFE work I have done with AEDs and defibrillators,  it always catches my eye when I see an AED.  Just last week I took pictures of an AED and surrounding signage in the Atlanta airport.

As I did, you might notice a few design-related things:

1. The AED Sign is one of the largest ones I have seen.  If you think of running around a busy and visually cluttered terminal, there is no way this sign can be too big
2. The AED is below the sign, but having other items so close might warrant a second sign; plus the added bonus that your vision might be blocked from one or the other sign by people.
3. The directions on the AED cabinet are not really clear.  Do you yank it open?  Break the glass?  If the alarm sounds when you open it, why not have “it” call 911?
4. Perhaps it would be ominous, but having a poster on CPR and the main steps for using an AED (like you see in restaurants showing the Heimlich Maneuver steps for choking)

What are your thoughts?

Some aspects of this Blog creation tool (WordPress) are very usable.  That is, they are intuitive to use without training or reading online “help”.  I will describe three types of HFE issues with the less intuitive aspects of this software tool:

1) Some aspects of the tool take some scanning and rescanning across the top and side bar menus to find.  The ones that seem to mimic MS Word, are the most straightforward, but there are some that are “grayed out” or are inscrutable icons.  By the third time I used this tool, I could remember where most were and use them fairly quickly.  My guess, though, is that if I went away from this tool for weeks or months, I would need to travel a learning curve again.

2) Other aspects take a bit of time to find, such as creating links, but then are pretty easy to find and use the next time.

3) One MAJOR tool that has been hard to find and use is the function for YOU to get email notification of the Blog entries.  I think I finally found it after searching 3-4 times, but I want to test it upon myself before saying you should try it.

 The three categories of HFE issues I talk about above are those found with many device interfaces.  You will notice that category #1 and #2 will fade in my memory as I become a regular user.  #3 is going to be a recurring bane of this tool.  #1 and #2 are unfortunately the type of issues that will haunt all of your intermittent users, skittish users, and distracted users.  These are unfortunately the user types that operate many of your devices.  Your expertise (and faded memory) will work against you as you refine and finalize your designs.  HFE tools, especially usability testing, is your defense against your faded memory of minor or moderate flaws that often have major consequences.

For those who like to read more aout this ”learned intution“, I have provided a link.  For those who like demos, find a FedEx logo and look hard for the “arrow” in it.  Once you find it, or get mad and have to Google it to find it, you will soon find it harder and harder to remember not knowing it is there.  Worse yet, you will slowly lose your empathy for those who don’t see it quickly.

In future Blogs, I will comment about some specific device-facilitated adverse events that I hear about.

Any of you helping your child with grade school homework have experienced feelings of surprise, pride, irritation, and nausea.  Surprise and pride over the depth of questions.  Irritation and nausea over our limitations in answering the so-called simple questions.

Last night my daughter needed my review of her 5th grade essay on convincing others to visit a place that she loved.  She loves writing stories and has a very interesting style that is born out of watching Pokeman and reading Hardy Boy books.  I quickly noticed that her essay was actually a first person account of our trip to Universal Studios – not in the systematic, 5-paragraph, and outline-driven style of pursuasive essays.  As I pushed her to write an outline, she kept pushing me with questions that challenged the useful nature of this style.  Her toughest question: “will they read it if it’s organized, but boring”.  She wasn’t arguing to turn it into a cartoon or music video…she just wanted “data” that standard essay was more effective than story narrative (with surprising twists and lots of action words).  We finally agreed that she could have elements of both styles.

This interaction got me thinking about how I have watched people actually read “stuff”.  From journal articles to small booklets to huge handbooks, how do people actually interact with various formats.  I’ve seen many usability studies of devices and software where the users manual or quick reference guide were used in very interesting ways (i.e., non-linear).  A few trends I’ve seen:

1. People thumb through and skim — not study
2. Pictures and big headlines are eye “stops”
3. One page guides are almost NEVER flipped over

 So, the cleverness and time needed to create useful written guidance should equal the resources to create the words themselves.  Asking 10 year old kids will reveal this…and, doing usability tests in a way that allows people to read and be guided as they would in real life.