Making it easier to do the right thing
Multidisciplinary
Michelle Clark
Training and Research Officer
(Health Psychology)
NHS Education for Scotland
michelle.clark@nes.scot.nhs.uk
Mark Johnston
Training and Research Officer
(Patient Safety)
NHS Education for Scotland
mark.johnston@nes.scot.nhs.uk
0131 656 3258
Culture
Workspace
Teamwork
Task
Organisation
@markjohnston71
Impact on behaviours and abilities
Quality Education for a Healthier Scotland
Adapted
from
Catchpole
Human Factors case study – Hand
hygiene behaviours of final year
medical students
Quality Education for a Healthier Scotland
Multidisciplinary
Pilot study – what we did
• Final year medical students at University of
Dundee Medical School
• Mixed methodology
Multidisciplinary
Qualitative (n=9)
Quantitative (n=30)
Questionnaire assessing
•Predictors of HH behaviour
•Barriers & levers to HH
behaviour
Based on students’ final year
‘ward simulation exercise’
assessment video
‘Self-explanatory’ interview
Categorical content analysis
using HF & Health Psychology
theory frameworks.
Quality Education for a Healthier Scotland
Results – Questionnaire
Predictors of behaviour
Multidisciplinary
Attitudes
Normative
beliefs
Perceived
behavioural
control
Behaviour
intentions
Behaviour
Theory of Planned Behaviour (Ajzen &
Fishbein, 1980)
Quality Education for a Healthier Scotland
Results – Quantitative
Barriers & Levers
(Theoretical Domains Framework (TDF) Michie et al 2008)
Multidisciplinary
• The higher the number of barriers, the less HH behaviour is
carried out
• Compared TDF domains based on levels of compliance
(high or low)
Mean
scores
20
18
16
14
12
10
8
6
4
2
0
**
**
Low Compliance
High Compliance
Quality Education for a Healthier Scotland
Results – Qualitative
‘Self-explanatory’ interview
Multidisciplinary
Observable HH behaviour low (despite high self reported HH)
Individual factors
Positive impact
• Attitudes & beliefs
(capabilities &
consequences of HH)
•Motivation
Negative impact
•Stress & anxiety
•Human cognition &
memory (mental load,
dual processing,
primacy effects
Task related
factors
Environment
factors
Negative Impact
Multiple tasks
•Switching between
multiple patients
•Changing symptom
presentation
•Problem solving
nature of tasks
Positive Impact
•Multiple gel bottles
•Prominent location
Negative Impact
•Layout of ward
•Layout of
paperwork/forms.
Quality Education for a Healthier Scotland
HH Pilot study (cautious) conclusions
• Clear intention-behaviour gap (self report & observed HH
behaviour)
Multidisciplinary
• Cognitive factors & beliefs about capabilities are barriers to
HH (in this group)
• Making several decisions within a high pressure
situation lead to high cognitive load which negatively
affects memory – automaticity not achieved
• Need to believe you are capable of performing HH
• Attitudes towards HH & Social influence (especially from
influential staff members) can predict HH behaviour
• Primacy effect evident in practice of WHO 5 moments, but
not recency effect (forgot moments 4&5).
Quality Education for a Healthier Scotland
Implications...
Multidisciplinary
Teaching of Hand Hygiene behaviour
• Impact of stress/anxiety and cognitive load on HH
behaviour & make behaviour automatic even in stressful
situations
• Other prompts to remind & encourage habits at more of the
WHO moments.
Quality Education for a Healthier Scotland
So, some thoughts on why…?
Bad people?
Error occurs due to
Systemic and Systemic
induced Individual failure
Negligence is not the
same as error, both may
result in harm
Quality Education for a Healthier Scotland
Multidisciplinary
Multidisciplinary
10
5
HF facilitators workshop Sept 11
Quality Education for a Healthier Scotland
You’re amazing!
Quality Education for a Healthier Scotland
Multidisciplinary
Why do we make mistakes?
• Sometimes we do the wrong thing, consciously and
sub-consciously
Quality Education for a Healthier Scotland
Multidisciplinary
Multidisciplinary
Quality Education for a Healthier Scotland
Individual Autonomy
VERY UNSAFE SPACE
Driving 100 mph
illegal for all
Driving
Normalisation of
75 mph –
Deviance
the ‘illegalillegal’
space (for
Driving 64 mph
almost all
-the illegalof us!)
normal space
5%
50%
80%
Multidisciplinary
Individual
Pressures
Perceived
Vulnerability
The posted
speed limit is
60 mph- the
‘legal’ space
<1%
PERFORMANCE
Borderline Tolerated
Conditions of Use
Belief in
Systemsguidelines
100% percent of drivers
Adapted from Rene Amalberti
Quality Education for a Healthier Scotland
Even experts make mistakes
Multidisciplinary
Quality Education for a Healthier Scotland
Human Factors
A common language
Multidisciplinary
“Enhancing clinical performance through an understanding of the
effects of teamwork, tasks, equipment, workspace, culture and
organisation on human behaviour and abilities and application of
that knowledge in clinical settings” (Catchpole 2010)
“Making it easy to do the right thing” (Bromiley 2011)
Individual Worker
Organisational/
Management
-Safety Culture
-Managers’ Leadership
-Organisation communication
Work/Environment
Workgroup/Team
-Work environment
and hazards
(ergonomics)
-Teamwork
structures & processes
-Team Leadership
-Cognitive skills
•Situation awareness
•Decision making
- Personal resources
•Management of stress
•Management of fatigue
(Flin, Patey 2012)
Quality Education for a Healthier Scotland
The first lesson in reducing harm is
the realisation that we will and do
make mistakes
‘It’s the downside of having
a brain!’
Reason
Quality Education for a Healthier Scotland
Multidisciplinary
Multi-tasking - Our lazy brains would rather
default to system 1
2x2
=
17 x 379 =
4…System 1
6443…System 2.
Kahneman 2012
Quality Education for a Healthier Scotland
Multidisciplinary
Card suit change game
Multidisciplinary
Groups of three
• 1 Person deals cards, turning them face up in rapid succession and
estimates the passing of time
If you deal all the cards deal them again
• 1 person estimates the passing of time with no aid and counts the
number of times the cards change suit.
• 1 person times the activity using an aid and then focuses only on
recording the suit changes
When told to finish, separately record the time and number of suit
changes and compare your results
Quality Education for a Healthier Scotland
Where can we start?
Multidisciplinary
“Making it easy to do the right thing” (Bromiley 2011)
Work/Environment
-Work environment
and hazards
(ergonomics)
(Flin, Patey 2012)
Quality Education for a Healthier Scotland
Multidisciplinary
‘We cannot change the condition of those
who do the work, but we can change
the conditions within which they work’
Reason J. BMJ. 2000 March 18; 320(7237): 768–770.
Quality Education for a Healthier Scotland
Everyone, everywhere, every time
Good human factors design in health care
accommodates everyone
Not just the calm, rested experienced healthcare
worker
But also the inexperienced health-care worker who
might be stressed, fatigued and rushing.
Quality Education for a Healthier Scotland
Multidisciplinary
Multidisciplinary
Quality Education for a Healthier Scotland
Where can we start?
Multidisciplinary
“Making it easy to do the right thing” (Bromiley 2011)
Organisational/
Management
-Safety Culture
-Managers’ Leadership
-Organisation communication
(Flin, Patey 2012)
Quality Education for a Healthier Scotland
Multidisciplinary
‘We cannot change the condition of those
who do the work, but we can change
the culture within which they work’
Quality Education for a Healthier Scotland
What is your culture?
Multidisciplinary
Nurses
Managers
Doctors
Silo working?
Quality Education for a Healthier Scotland
Multidisciplinary
Hierarchies?
Quality Education for a Healthier Scotland
Do we pay attention to the Swiss cheese or do we blame?
Multidisciplinary
Our learned behaviour is
to blame an individual
Society, peers, media
Imperfect System
Our colleagues, ourselves?
Quality Education for a Healthier Scotland
Where can we start?
Multidisciplinary
“Making it easy to do the right thing” (Bromiley 2011)
Workgroup/Team
-Teamwork
-Team Leadership
(Flin, Patey 2012)
Quality Education for a Healthier Scotland
Lessons for Leadership in
changing culture
Culture change and continual
improvement come from
what leaders do, through
their commitment,
encouragement, compassion
and modelling of
appropriate behaviours.
Berwick Report 2013
Quality Education for a Healthier Scotland
Multidisciplinary
Where can we start?
Multidisciplinary
“Making it easy to do the right thing” (Bromiley 2011)
Workgroup/Team
Structures & processes
(Flin, Patey 2012)
Quality Education for a Healthier Scotland
Examples in healthcare…
•
Prescribing and dispensing
•
Hand-over/hand-off
information
•
Movement of patients
•
Order of tests
•
Preparation of medication
•
Multidisciplinary
If all of the processes
associated with these tasks
make sense and become
easier for the ‘human’ to
comply with, then patient
safety will improve.
Quality Education for a Healthier Scotland
Making it easier to do the right thing
PDSA example: Christopher
Multidisciplinary
Toilet training
Aim:
Christopher to
urinate into the
toilet bowl 100% of
the time by 30th
June 2010.
Quality Education for a Healthier Scotland
PDSA template
Multidisciplinary
Describe your first (or next) test of
change:
Person
When
responsible to be
done
Where to
be done
Demonstrate the correct way to urinate
into the bowl and indicate the negative
aspects of missing the bowl
Me
Downstairs
toilet
tonight
List the tasks needed to set
up this test of change
Person
responsible
When
to be
done
Where to be done
Christopher available
Me
tonight
Downstairs WC
Predict what will happen when the
test is carried out
What will determine if prediction
succeeds
Christopher will show understanding of
process and execute correctly
The floor will be dry

Quality Education for a Healthier Scotland
Example: DSA
Do
Christopher thought the demonstration amusing
and ignored it
Multidisciplinary
Study
0% compliance with the new process
0% reliability level
Act
Seek out ideas, develop new test cycle.
Quality Education for a Healthier Scotland
Example: next PDSA cycle
Multidisciplinary
A Human Factors approach!
http://www.amazon.co.uk/toilet-training-target-stickersHappeedays/dp/B002GZAWUK/ref=pd_sim_by_3
Quality Education for a Healthier Scotland
Making it easier to do the right thing
Multidisciplinary
Michelle Clark
Training and Research Officer
(Health Psychology)
NHS Education for Scotland
michelle.clark@nes.scot.nhs.uk
Mark Johnston
Training and Research Officer
(Patient Safety)
NHS Education for Scotland
mark.johnston@nes.scot.nhs.uk
0131 656 3258
Culture
Workspace
Teamwork
Task
Organisation
@markjohnston71
Impact on behaviours and abilities
Quality Education for a Healthier Scotland
Adapted
from
Catchpole