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Ergonomics
ISSN: 0014-0139 (Print) 1366-5847 (Online) Journal homepage: http://www.tandfonline.com/loi/terg20
More Holes than Cheese. What prevents the
delivery of effective, high quality, and safe
healthcare in England?
Sue Hignett, Alexandra Lang, Laura Pickup, Christine Ives, Mike Fray, Celine
McKeown, Sarah Tapley, Matthew Woodward & Paul Bowie
To cite this article: Sue Hignett, Alexandra Lang, Laura Pickup, Christine Ives, Mike Fray,
Celine McKeown, Sarah Tapley, Matthew Woodward & Paul Bowie (2016): More Holes than
Cheese. What prevents the delivery of effective, high quality, and safe healthcare in England?,
Ergonomics, DOI: 10.1080/00140139.2016.1245446
To link to this article: http://dx.doi.org/10.1080/00140139.2016.1245446
Accepted author version posted online: 07
Oct 2016.
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1
Publisher: Taylor & Francis
Journal: Ergonomics
DOI: http://dx.doi.org/10.1080/00140139.2016.1245446
More Holes than Cheese. What prevents the delivery of effective, high
quality, and safe healthcare in England?
Sue Hignett1*, Alexandra Lang2, Laura Pickup3, Christine Ives4, Mike Fray4, Celine
McKeown5, Sarah Tapley6, Matthew Woodward7, Paul Bowie8
*Corresponding Author
1*Prof. Sue Hignett
Professor of Healthcare Ergonomics and Patient Safety
Loughborough Design School
Loughborough University,
Loughborough, Leics.UK.
LE11 3TU
Tel: +44 (0)1509 223003
Email: S.M.Hignett@lboro.ac.uk
2Dr Alexandra Lang
Research Fellow
Human Factors Research Group
Faculty of Engineering
University of Nottingham
Nottingham, NG7 2RD
3Dr Laura Pickup
Implementation Science Research Fellow
NIHR CLAHRC South West Peninsula (PenCLAHRC)
University of Exeter
2
Exeter, EX1 2LU
4Christine Ives and Dr Mike Fray
Loughborough Design School
5Dr Celine McKeown
Link Ergonomics
Daneton Lodge, Manor Park
Ruddington, Nottingham
NG11 6DS
6Sarah Tapley
Tapley Ergonomics Ltd
47 Lower Brook Street
Ipswich
IP4 1AQ
7Matthew Woodward
Nuffield Department of Surgical Sciences
University of Oxford
John Radcliffe Hospital
Oxford. OX3 9DU
8Dr Paul Bowie
Programme Director (Safety & Improvement), NHS Education for Scotland
Honorary Senior Lecturer, Institute of Health & Wellbeing,
University of Glasgow
Scotland, UK. G3 8BW
Key words: Human Factors, Ergonomics, Education, Patient Safety
Word Count: 4,022
3
More holes than cheese. What prevents the delivery of effective, high
quality, and safe healthcare in England?
Abstract
What prevents the delivery of effective, high quality, and safe healthcare in the National
Health Service (NHS) in England? This paper presents 760 challenges which 330 NHS staff
reported as preventing the delivery of effective, high quality and safe care. Some problems
have been known for over 25 years (staff shortages, finance and patient complexity) but other
challenges raise questions about the commitment of the NHS to patient and staff safety. For
example Organisational Culture leading to ‘stifling bureaucracy’, ‘odds stacked against
smooth […] working’ and Workload resulting in ‘firefighting daily’ and ‘perpetual crisis
mode’. The role of Human Factors/Ergonomics professional input (engagement with safety
scientists) is discussed in the context of success stories and examples of Human Factors
Integration from other safety critical industries (Defence, Nuclear and Rail).
Practitioner summary
760 challenges to the quality, effectiveness and safety of healthcare were identified at Human
Factors/Ergonomics taster workshops in England. These are used to challenge healthcare
providers to think about a Human Factors Integration (HFI systems) approach for safety,
wellbeing and performance for all people involved in providing and receiving healthcare.
Key words: Patient Safety, Systems, Healthcare, Ergonomics, Human Factors Integration
4
Introduction
There have been many papers written on safety in the healthcare industry since 2000 (Kohn,
Corrigan, and Donaldson, 2000; Department of Health, 2000) but despite pockets of good
practice (Xie and Carayon, 2015) there seems to have been relatively little progress in
embedding safer practice, technology and changing culture (Bagian, 2012; Shekelle et al,
2013; Dixon-Woods et al, 2014a). Wears (2015) reflected on this (and other topics)
suggesting that the lack of progress is possibly due to ‘medicalization’ of the area (selective
engagement), where ‘a certain school of thought among health professionals – managed to
take it over, displacing other forms of scientific and professional activity, and turning it from
a reformist movement to a conventional, business-as-usual activity, ironically with the best of
intentions’. This includes a lack of engagement with safety scientists (including Human
Factors/Ergonomics (HFE) specialists) in contrast to the response by other safety critical
industries when tackling entrenched safety challenges (Ministry of Defence, 2008; Office for
Nuclear Regulation, 2014; Office of Rail and Road, 2008). The failure to utilise professional
expertise has been commented on by Peerally et al (2016) where root cause analyses for
serious untoward events (including death) will be ‘typically conducted by local teams, not the
expert accident investigators who are proficient in systems thinking and human factors,
cognitive interviewing, staff engagement and data analysis that are characteristic of other
high-risk industries’.
In the UK there have been initiatives to introduce HFE since 1990 after a change in
legislation in 1986 when Crown Immunity from prosecution under the Health and Safety Act
1974 (Seccombe, 1995) was removed. This meant that the UK National Health Service
(NHS) had to comply with safety legislation as hospitals and other care locations were
considered to be places of work. HFE input was used in 1980s – 2000s for building design
(Hilliar, 1981), occupational health (Straker, 1990) and systems approaches to embed HFE as
part of the organisational culture (Hignett, 2001). The interest in safety moved from staff to
patients after the Bristol heart scandal (Department of Health, 2002) with seminal
publications on the level of iatrogenic harm (Kohn, Corrigan, and Donaldson, 2000;
Department of Health, 2000) reporting that at least 10% of patient admissions may result in
some form of harm. A National Patient Safety Agency (NPSA) was established in 2005 with
some excellent Human Factors projects (Norris, 2009) but was closed in 2012 with all the
HFE professionals leaving NHS England.
5
In 2013 a Concordat was signed by 16 healthcare agencies in England (including professional
regulators, inspection agencies and education providers) stating that ‘a wider understanding
of Human Factors principles and practices will contribute significantly to improving the
quality (effectiveness, experience and safety) of care for patients’ (National Quality Board,
2013). One of the initiatives to implement the Concordat was a series of HFE taster
workshops (2 hours) in collaboration with the UK professional body for HFE (Chartered
Institute of Ergonomics & Human Factors, CIEHF) to a wide range of NHS staff. The
workshops aimed to raise awareness of HFE as a scientific discipline and profession amongst
health care professionals, leaders and decision-makers.
This paper will (1) present and discuss the challenges which the NHS staff felt prevented the
delivery of effective, high quality and safe care and (2) discuss how a HFE approach could be
applied to some of these challenges.
Method
A series of HFE awareness raising (taster) workshops were delivered to over 500 healthcare
staff through Health Education England (HEE)1 regional groups
(https://www.hee.nhs.uk/hee-your-area) between June and December 2015. The 2 hour
workshop (accredited as a short course by CIEHF) provided an introduction to HFE
principles and applications based on the International Ergonomics Association Core
Competencies (IEA, 2001). The learning outcomes were to demonstrate an introductory
knowledge of HFE principles and practices; discuss HFE problems in terms of understanding
capabilities as design challenges for all the humans (both staff and patients); and discuss
interventions in current systems (culture and processes) through re-design rather than adding
work. The details of the workshop have been reported elsewhere (Hignett, 2015).
A pre-workshop online survey was developed and piloted with 37 staff in 2 preliminary
workshops. Changes were made to simplify the content (e.g. condensing clinical specialities
into higher level categories) and add an option to decline to record any safety challenges.
The survey collected data about professional roles with options for direct healthcare provider,
1 HEE is a non-departmental Government Public Body that exists to support the delivery of excellent healthcare
and health improvement to the patients and public of England by ensuring that the workforce of today and
tomorrow has the right numbers, skills, values and behaviours, at the right time and in the right place
6
manager (and combination of direct provider/manager), support to care provider (e.g.
education, audit) and operational services (e.g. information technology). The clinical service
sector was recorded as acute, rehabilitation/community hospital, GP practice, mental health
organisation, hospice care, local authority, community health organisation, community
pharmacy or social care organisation.
The survey asked the workshop delegates to complete free text fields to identify the top
challenges which they felt prevented the delivery of effective, high quality and safe care.
Responses were received from 330 healthcare staff identifying 760 challenges. The free text
narrative data were imported into NVivo 10 (http://www.qsrinternational.com/what-is-nvivo)
and a two stage analysis was carried out by firstly organising, reducing and describing the
data through primary coding using the Query (Word Frequency) function in NVivo to give a
literal Tag Cloud output (Figure 1). The second stage of interpretive analysis used an
iterative process (Hignett and McDermott, 2015) with the Tag Cloud categories for ‘top
down’ coding and additional emergent categories from ‘bottom up’ coding. The generation of
codes continued until theoretical saturation (no new instances) was achieved and then all data
were reviewed to check for exhaustive and inclusive coding.
Figure 1. Word cloud of challenges preventing the delivery of effective, high quality and
safe care
7
The preliminary Tag Cloud codes used for group work discussions within an HFE framework
(Figure 2; Hignett, 2015) were:
• Resources: including finance, staffing (including numbers, competencies, workload,
stress/burn out, and training) and technology (missing and defective equipment).
• Systems: including communication, Information and Communication Technologies
(ICT), reporting tools, patient care pathway, policies and procedures, interconnectivity
between patients, care providers, technology systems and lack of standardisation.
• Culture: including hierarchies (clinicians, managers, non-registered staff), instability (of
NHS at a national level, individual organisations and local teams), silo-working
(professions, specialities and sectors), increasing demand and service expectations (from
patients and NHS targets), blame culture, and a lack of clear vision leading to
sustainability.
Figure 2. HFE framework used in Taster workshops (Hignett, 2015)
No additional data were recorded from discussions at the workshops so a secondary more
detailed analysis was carried out on the narrative data from the survey. This ensured that all
data were included (accountability) to give an audit trail for internal validity. The resultant
higher level codes were subsequently discussed and presented to healthcare audiences to
address issues of external validity.
WHO WHAT WHEN WHERE HOW WHY
Scope of issue/challenge/problem
Define stakeholders
Participatory - Inclusive Design
Physical factors
Anthropometry (reach/clearance), Biomechanics, Postural Analysis,
Vision (and sight lines), Hearing, Fatigue, Thermal comfort
Cognitive factors
Mental models, Individual decision making, Variability,
Human-Computer Interaction , Navigation (unfamiliar environments)
Organisational factors
Hierarchies (professional, employer and staff-patient relationships),
team stability, decision making (authority, accountability, responsibility,
delegation), procurement
Investigate/explore
HFE methods
8
Results
The workshop delegates included direct healthcare providers (n=135, of whom 7 were also
managers), managers (n=76), support staff (n=35) and other staff (operational services,
clinical researchers). Most were from the acute sector (63%), with some staff from
community services (13%), local authority (7%) and mental health (6%) settings. To gain an
understanding of clinical activities, delegates were asked if they were registered with a
professional regulator. Doctors (General Medical Council) accounted for 35% of delegates,
nurses (Nursing and Midwifery Council) for 33%, allied health professionals (Health Care
Professionals Council) for 16%, pharmacists (General Pharmaceutical Council) for 8%,
dentists (General Dental Council) for 3% and other professions for 4%. Although the
workshops were presented to over 500 staff, workshop attendance varied across locations
(with some failing to keep attendance registers).
The secondary thematic analysis recoded the challenges into 8 higher level themes (Figure 3):
organisational culture (26.4%), staff numbers and competency (20.5%), pressure at work
(19.4%), risk management culture (10.8%), communication (10.5%); resources (6.4%),
finance/budget (3.6%), and patient complexity (2.4%).
Figure 3. Challenges preventing the delivery of effective, high quality and safe care
26.4%
20.5%
19.4%
10.8%
10.5%
6.4%
3.6%
2.4%
0% 5% 10% 15% 20% 25% 30%
Organisational culture
Staff number and competency
Pressure at work
Risk management culture
Communication
Resources
Finance/budget
Patient complexity
9
At this stage a pragmatic decision was taken to recognise that HFE may be beneficial in
some, rather than all, themes. For example the themes of patient complexity (2.4%), staff
numbers and competencies (20.5%) and finance (3.6%) have been known for over 25 years
(Audit Commission, 1991) relating to the ageing and increasingly frail population, shortage
of nurses and other staff, and political changes. These themes are widely discussed elsewhere
(for example, Iacobucci, 2016) and will not be further discussed in this paper.
Some of the data were coded in more than one theme, but where possible the data were coded
exclusively in individual codes; for example some ICT issues were recorded as
administration bureaucracy (in the Organisational Culture theme) to represent the policy
whereas challenges associated with individual communication interfaces between sectors and
individuals were coded to the Communications theme. Examples of the themes and
illustrative quotes are as follows:
Organisational culture (26.4%)
• Leadership: including accountability, reporting structures, lack of management
support/vision ‘executive level engagement of initiatives’ (D155); lack of support for
innovation and change ‘inability of staff to make small incremental changes to the own
and local practice’ (D330); challenging personalities within teams; different values and
drivers ‘organisational moving obstacles - too many moving parts meaning that the odds
seem to be stacked against smooth theatre working rather than in their favour’ (D20);and
individual agendas ‘people looking at only their interests and covering their own back,
therefore leading to over-defensive medicine and management of personnel in the NHS’
(D222).
• Models of working (system culture): including complex and/or historical systems patient
pathways ‘complexity of policy/procedure’ (D213); lack of integration (silo working) and
standardisation including discharge; organisational policies and processes ‘clinical
guidelines that don't make accessing information easy’ (D25); and roles/responsibilities
‘difficult in-house structures which means that reporting lines are not transparent’ (D89).
• Administration bureaucracy: including duplication (task and paperwork) ‘stifling and
increasing bureaucracy within the NHS taking care away from patients’ (D65); ICT
‘non-seamless, user unfriendly IT’ (D131); and purchasing processes.
10
Pressure at work (19.4%)
• Reactionary system operation: including department full/blocked; increasing number of
patients ‘firefighting daily’ (D27); and discharging patients too early ‘perpetual crisis
mode, difficulty making time for thinking and planning, implementation, follow through’
(D293).
• Staff: physical and cognitive (stress) wellbeing; morale, commitment and enthusiasm
‘stress and concurrent sickness rates due to pressures to meet targets, patients with
higher acuity and care needs’ (D84).
• Time pressure: ‘time poor over stretched staff becoming disengaged in their roles’
(D257), ‘lack of time to obtain patient and carer views in other than perfunctory ways’
(D327).
• Coping: including work force resilience; competing priorities; following procedures; lack
of teamwork; and lack of team continuity ‘lack of continuity in the team I work with -
Nursing team on my ward is not consistent. We do not have single 'sister in charge' and
there are frequent changes from day to day which impedes development of team
relationships which improve outcome for patients on the ward. Also ward rounds are led
by 4 different people across 5 days in the week - which feels disjointed’ (D28).
Risk management culture (10.8%)
• Focus on safety issues: including blame; human error; safety; HFE; Quality Improvement
(QI); risk management; and clinical governance; ‘recognition of safety issues’ (D72),
‘organisations focusing on data rather than the 'what have we done about it?'(D84),
‘hierarchical/ pervading blame culture’ (D91).
• External pressures (e.g. regulations and inspections): ‘too many other
priorities/expectations e.g. from Regulators who also don't appear to be on board with
how to truly improve quality’ (D190).
Communication (10.5%)
• Communication system between sectors: ‘fragmentation between services’ (D296),
multi-disciplinary teams/staff including handover and outliers, and patients’
expectations (compliments and complaints) ‘systems design i.e. interconnectivity
between people, care providers, technologies’ (D129).
• Communication lack and barriers ‘communication physical barriers - bleeping the
correct person, being bleeped, finding a phone to answer back on’ (D20).
11
• Communication: distractions/interruptions ‘lack of consideration to environmental
factors that impact on humans and processes e.g. distractions/interruptions’ (D323).
Resources (6.4%)
• Including equipment (missing, available, defective etc.); limited space and environmental
problems ‘materials inaccessible or difficult to locate in a timely-fashion’ (D69).
Discussion
Before discussing these themes and the role of HFE, it is acknowledged that the data have
limitations due to the self-selection by delegates for both workshop attendance and
completion of the pre-workshop survey.
The five themes have been represented in a modified [Swiss] Cheese model (Figure 4) to
represent the greatest challenges to the delivery of effective, high quality and safe care. The
lack of barriers for each theme is represented by the size and number of holes in each cheese
slice.
Figure 4. More holes than [Swiss] Cheese to represent the lack of barriers for unsafe acts
(inspired by Reason, 2000)
12
In this paper, the Organisational Culture theme is represented as ‘more hole than cheese’ as it
continues to be an ‘ultimate challenge’ (Leape, 2004). Organisational culture as a theoretical
concept has been discussed and defined by many academic disciplines (Helmreich and
Merritt, 1988). This has led to opportunities for healthcare safety initiatives to be selective
both about the term and the concept depending on the interests and focus of the researchers.
Over the last 30 years there have been many appeals for cultural change in the NHS with
some success ‘in changing some of the surface manifestations of medical culture … [but]
less successful in penetrating the deeply entrenched values and beliefs (and power bases) that
underpin clinical practice’ (Davies, Nutley and Mannion, 2000) and it is likely this will
continue with new initiatives at least every 5-10 years to restructure at national and local
levels.
One of the first issues often raised about healthcare organisational culture is the complexity
of the dynamic system(s) within care organisations, across care sectors and between
professional domains (Carayon and Wood, 2010). The organisational complexity of the NHS
was previously represented and compared with other sectors by Hignett (Figure 5: 2003) to
show the NHS hierarchy with multiple professional and management lines. This was
contrasted with other service (public) domains with Defence as a multi-professional
organization with one managerial line and Education as a single (combined) management and
professional structure.
Figure 5. Management hierarchies in Service Industries (modified from Hignett, 2003)
Education
One management line
One profession
Defence
More than one profession
One management line
Healthcare
More than one profession
More than one management line
13
We suggest that one of the first contributions HFE experts can deliver is understanding and
experience of safety integration within complex systems. HFE input has been successfully
delivered in the UK Defence sector across domains for the army, navy and air force and
across many professional groups. There are both examples of HFE Standards (Ministry of
Defence, 2008; 2015) and definitions for HFE Suitably Qualified and Experienced Person
(SQEP; Ministry of Defence 2015). There are also examples from other complex safety
critical industries, for example Nuclear and Rail. In the Nuclear sector the HFE SQEP roles
have been delivered as ‘both in-house and consultants to move the HFE programme
forwards’ (Office for Nuclear Regulation, 2014). In healthcare, the concept of SQEP has
been discussed by Williams and Bagian (2010) as part of the HFE in patient safety training
program at the Veterans Health Administration National Center where they comment that
‘clinicians understand that they put patients at risk when diagnosis and treatment of
pathophysiology lie outside their expertise’.
The scope of HFE potential at the organisational level can be seen from the UK Rail industry
the last 17 years where HFE has successfully been integrated across multiple organisations
(Network Rail, Train Operating Companies, Railway Safety and Standards Board -
http://www.rssb.co.uk/improving-industry-performance/human-factors). The UK rail
regulatory bodies (Office of Road and Rail (ORR) and the Rail Accident Investigation Board
(RAIB)) have SQEP HFE professionals employed to review and advise on risk and safety
management. The HFE principles are embedded and used to ‘inform any major change as
well as evaluations of intended or actual system modifications with areas of activity
embracing culture, competence, cognition, equipment, environment, functions and tasks as
part of a systems approach’ (Wilson, 2014) with a clear structure for application (Figure 6).
14
Figure 6. Human Factors in the Rail Industry (Office of Road and Rail;
http://orr.gov.uk/publications/guidance/health-and-safety/human-factors-guidance)
The Pressure at Work slice also has large holes to reflect the lack of barriers for what was
described as a reactionary system with full/blocked departments, time pressures, competing
priorities and coping strategies including work force (rather than system) resilience. There are
research studies linking excessive workload to increasing errors, for example nurses working
shifts longer than 12 hours or for more than 40 hours per week (Rogers et al, 2004; Olds and
Clarke, 2010) and interns working ‘frequent shifts of 24 hours or more’ (Landrigan et al,
2004). In the aviation industry workload, as flight time limitation, has been addressed since
1944, with harmonised minimum European criteria from 2008 and consideration for human
performance throughout the 24 hour period (‘Window of Circadian Low’; European Cockpit
Association, 2007).
Healthcare practitioners frequently modify their work practices as part of individual and team
coping strategies. This ability to adjust to uncertainties provides resilience within the system
to sustain and balance the goals of safety and efficiency. However, such adjustments may
also be cited as a contributory factor for an unsafe event (incident) especially where
investigations focus on human behaviour (blame culture) rather than proactive risk
There are three main aspects to Human Factors that can impact on people's health and
safety-related behaviour.
• Job: Tasks, workload, environment, displays and controls, procedures.
• Individual: Competence, skills, personality, attitudes, risk perception.
• Organisation: Culture, leadership, resources, work patterns, communications
Human Factors cuts across the boundaries between many traditional railway industry
disciplines and yet adequate management of Human Factors is often overlooked. Human
Factors are not a series of independent issues to be conveniently addressed in isolation,
or on a piece-meal basis. Nor can Human Factors be effectively incorporated just before
the end of a project or design process. Instead, Human Factors considerations should be
integrated throughout the lifecycle of systems development, functions of the owner
organisation and the different roles of individuals in project teams.
15
management. We suggest that this has created a misunderstanding in the term resilience,
where staff training (human resilience) in leadership, team work and communication is
proposed rather than system resilience; this results in [trained] staff continuing to work in
pressured conditions. The term resilience, in the context of HFE, relates to resilience
engineering (Hollnagel, Woods and Wreathall, 2011) and seeks to understand how a system
can be engineered to anticipate and monitor variability in a system whilst recognising why
this occurs, and how engineering (system) responses can preserve safety. Increasing the
human resilience ignores the influence of the whole system and is likely to result in increased
pressure on staff, as reported by the workshop delegates.
Risk Management slice has been used to cover a wide range of operational issues including
quality improvement, financial risk (corporate governance), and clinical governance (Scally
and Donaldson, 1998). In the NHS, quality and safety were explicitly linked in the late 1990s
following the Bristol heart scandal (1984-1995; Department of Health, 2002). There have
been multiple initiatives which have included clinical audit, clinical effectiveness, education
and training, research and development, openness, risk management, and information
management. As mentioned earlier, the NHS tends to restructure every few years and these
initiatives have been led by the Commission for Health Improvement (CHI, 1999-2004; Day
and Klein, 2004), Commission for Health Audit and Inspection (CHAI, 2004-2009), Care
Quality Commission (2009-), the National Quality Board (2009-), National Patient Safety
Agency (2001-2012), NHS Institute for Innovation and Improvement (2005-2013), NHS
Improving Quality (2013-2016), and NHS Improvement (2016- ). In 2016, the Care Quality
Commission reviewed the way that NHS acute hospitals investigated serious incidents and
gave five recommendations. HFE professionals can directly respond to two of these by
providing ‘skilled analysis to move the focus of investigation from the acts or omissions of
staff, to identifying the underlying causes of the incident’ and ‘human factors principles to
develop solutions that reduce the risk of the same incidents happening again’.
The challenges of Communication within complex systems are not new. Nembhard and
Edmondson (2006) discussed an entrenched status culture in healthcare which contributed to
the barriers for integrated working across sectors and professional boundaries, and possibly
also to patient safety events (Institute of Medicine, 2003). Information systems in healthcare
do not currently benefit from standards which require the application of HFE or user centred
design principles (BS EN ISO 13407, 1999; BS EN ISO 9241-210, 2010). The Health and
16
Social Care Information System (HSCIC) is the UK national provider for information, data
and technical systems in healthcare. It is responsible for the setting up and managing of ICT
systems in healthcare and sets the standards and guidelines for data collection and reporting
of information. We suggest that the current approach is driven by technology providers
offering like-for-like technical solutions for existing systems as a ‘one size fits all’ solution
rather than working with HFE professionals to understand and redesign the ICT systems in
contrast to the mandatory involvement of HFE for Defence procurement (http://www.scs-
ltd.co.uk/wp-content/uploads/Case-study-DTT.pdf). This approach may create a stagnant
ICT culture where healthcare staff are stifled by lack of engagement with their working
priorities and operational needs despite optimism about benefits from ICT and opportunities
for a more co-ordinated ‘joined up’ way of working (Waterson, 2014). HFE has yet to be
fully integrated nationally into either the development process or evaluation of healthcare
technology systems which in some cases mimic unreliable or inefficient paper version and
require staff to 'work around' the final product (Clarke, Belden and Kim, 2014).
Accessing Resources (equipment and consumables) is represented in Figure 4 as the slice
with the fewest holes suggesting a fairly robust barrier,. However, this may be due to the
coping culture rather than a reflection of good practice in procurement and logistics. Cox,
Chicksand and Ireland (2005) commented on a healthcare procurement dichotomy of
‘clinical effectiveness versus cost effectiveness’ in terms of the ‘rights of clinicians to design
and specify requirements individually without any real consideration of the commercial
consequences of their actions’. This describes a tension which HFE is well-placed to support
through product evaluation and user trials (Hignett, 1998; 2003). A Usability and HFE
standard has been established since 2008 (ISO 62366) and makes explicit links to the
associated risk management standard (ISO 14971, 2007) to ensure that manufacturers
consider potential risks of system use and integration and also, where relevant, the lifecycle
of medical device software (IEC 62304, 2006). The integration of HFE into the building
design process has been encouraged since the 1980s (Hillier, 1981) and most recently with an
evidenced-based resource from the USA (Taylor and Hignett, 2014) encouraging a systems
approach to safety in building design (https://www.healthdesign.org/insights-solutions/safety-
risk-assessment-toolkit-pdf-version).
17
Conclusion
So why is the NHS still lagging behind other public sector safety critical industries in the
application of HFE principles and practices (SQEP)? The taster workshops identified the
lack of barriers (more holes than cheese) in NHS systems. We propose that the way forward
is to learn from other industries, in particular Defence, Nuclear and Rail. There needs to be a
discussion about principles for Human Factors Integration in healthcare (Figure 7) to address
the challenges of organisational culture, pressure at work (workload), risk management,
communication and resources.
Figure 7. Human Factors Integration principles for Healthcare: who, what, when, where, how
and why
This presents a challenge in England where the primary response to patient safety has been to
provide behaviourist training (Crew Resource Management; Catchpole, 2013). An HFE
approach does not incorporate training as its primary element although it is important that
staff receive training in the systems of work and work equipment to (hopefully) be able to
respond when things go wrong. For predictable challenges, an HFE system will be designed
to respond and be resilient to all conditions, for example in infection prevention and control
‘design systems, the workplace, and devices that influence correct, compliant human
behavior and make it easy and efficient to do the right thing at the right time’ (Anderson et
al, 2010).
Integration: who, what, when, where, how and why
– Who = Every one: patients, staff, visitors, contractors, NHS
policymakers, board members, commissioners etc.
– What = Safety as performance (quality) and wellbeing issue
– When = All the time (including emergencies, CBRNe etc.)
– Where = All sectors and locations
– How = Embedded and SIMPLE by design of systems including
workplace procedures, undergraduate and postgraduate training,
national policy and procurement etc.
– Why = Human sympathetic (we all have limitations…)
18
The role of the patient is central to an HFE approach and our late colleague, Prof. John
Wilson reflected on his experience as a patient by describing ‘systems of systems’ in
healthcare as nested and overlapping (parent/sibling) systems; ‘bed in a hospital is a system,
the patient monitoring equipment is a sibling system, the two together plus the patient’s room
comprise another system, …; whereas the radiology or scanning equipment, the drugs
dispensary, the beds, the ambulances are all systems, but together can be seen as a system of
systems when looking at maintenance and replacement regimes’ (Wilson, 2014).
Although many of these challenges are not new, the survey information has provided an
opportunity to present and discuss NHS staff concerns about the delivery of effective, high
quality and safe care. The role of HFE professional input has been discussed with examples
from other UK safety critical industries and we believe that Human Factors Integration is
vital to enhance safety in healthcare.. However, we suggest that no progress will be made
unless the HFE input is delivered by qualified (SQEP) professionals in collaboration with
healthcare staff so that the full potential of HFE in healthcare can be realised.
Acknowledgements
This project was a collaboration between Health Education England national and regional
groups (East Midlands, East of England) and the Chartered Institute of Ergonomics & Human
Factors. We would like to thank both organisations for their continuing support in applying
Human Factors & Ergonomics to improve safety, wellbeing and performance in the
healthcare industry. Special thanks to Patrick Mitchell, Renée Knopp, Anna Lee and Margit
Veveris from Health Education England; Chetna Modi, Waseem Shahzad and Will Green
from Health Education East Midlands and Alex Baxter, Ann Smith and Robin Holland from
Health Education East of England. Finally, thanks to Ruby Allen for her creative expertise
for the modified cheese model.
Disclaimer
The opinions expressed in this article are the authors’ own and do not reflect the view of
Health Education England, NHS England, or the Department of Health.
19
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