Human factors are what shape our behaviour in the context of the systems of which we are a part.

They are all the things that make us different from logical, completely predictable machines - how we think and relate to other people, equipment and our environment.

In essence, they are the glue that holds everything in a complex system together - because that is what humans do best.

Drawing upon human biology, psychology, engineering and design, the scientific discipline of human factors (also referred to as ergonomics) aims to develop and apply knowledge and techniques to optimise system performance by recognising the human as the most important part of the system.

If we design our systems around what people are good at, and use our knowledge of failures to build systems that avoid human fallibilities, we will reduce errors, improve performance, and enhance wellbeing. The study and application of human factors is therefore about understanding how to get the best out of our highly evolved human abilities.

Where are we up to in healthcare?

While human factors have been at the heart of technological design and professional practice in most safety critical industries over the past 60 years, application in healthcare settings is still in its infancy.

Nevertheless there is already a growing evidence base that supports the view that reductions in avoidable harm to patients and enhanced system productivity are both very possible through a better application of human factors knowledge.  

Most significantly perhaps considerable support for these approaches is now emerging among clinicians, managers and users of health services alike. 

Early work around human factors in healthcare has also tended to focus on understanding incidents, teamwork, communication and overall safety culture and on the translation of principles from aviation to healthcare. This has demonstrated a very useful but limited application of the human factors approach. 

More recent studies however have also used human factors frameworks to improve equipment design and procurement; design job roles by understanding the demands and tasks of individual healthcare practitioners in real contexts rather than in the abstract or “ideal”; improve what and when training is delivered – in particular emphasising “learning through use”; and ultimately and perhaps most powerfully, the integration of these complex system components into a coherent whole.

Optimal human performance is more likely when behaviour is understood within the context and patterns of interaction in which it occurs. Put very simply the human and system are inseparable - they are part of the same. Unsafe behaviour arises from unsafe systems of work and vice versa.  

So why is it that we spend so much time and effort trying to educate individual or change team behaviours in contexts that will continue to working against people despite their very best efforts?

The Clinical Human Factors Group (CHFG), an independent charitable body supported by the Health Foundation, aims to stimulate dialogue about exactly these issues and to demonstrate through concrete action how a better understanding of the role of human factors can have a significant impact on safety, quality and productivity in healthcare

As a broad network of healthcare professionals, managers and users of services have partnered with experts in human factors from healthcare and other high-risk industries, the CHFG manifesto is built on three pillars of activity.

1. Human Factors education & training: For many years other “high risk” industries such as aviation and other safety critical industries have included human factors in the core curricula of professional staff. Moreover, they ensure that practitioners and teams are reassessed throughout their professional careers to ensure that “non-technical” skills are maintained. 

While some good progress in healthcare is being made through the increased use of simulation training, health professionals are not routinely trained and examined as part of ongoing development.

2. Building “high reliability” organisations: The characteristics of highly reliable organisations (HROs) are well documented. Ultimately HROs aim to design systems and processes which actively and systematically work to create psychological as well as physical safety.

They also aim to develop cultures that support people to raise and listen to the views and concerns of others. Indeed in most high-risk industries this is seen as crucial and it is the failure to “speak up” that is considered to be the offence rather than the other way around. 

HROs also treat human factors, knowledge and expertise in the same way as other managerial specialisms such as finance, HR and so on. They use this expertise to help them work back from incidents to everyday problems, and from everyday problems to solutions that focus on making the best use of human abilities - not just adding work or new skills, or urging people to remember better or try harder, all of which actually increase the chance of errors.

3. Intelligent regulation and independent investigation: The current system of safety supervision, regulation and investigation in healthcare is divided between several agencies, is overly complex and seen as remote and increasingly ineffective by practitioners and the public alike.

Compared with other safety critical industries the NHS lack the required forensic skills to take account of underlying systemic and human factor causes of serious error, which necessarily form the basis for prevention and improvement. In other industries, independent investigation is mandatory for all serious failures and is carried out by highly trained expert investigators.

With the public inquiry at Mid Staffordshire now well underway the systemic and contextual issues that led to such significant patient safety failures are going to be brought into sharp focus. The extent to which human factors will be explored as an issue within the inquiry will be interesting to note, because they are undoubtedly present.

Healthcare should aim for the maturity that other industries benefit from and it is hoped that, in the not-too-distant future, consistency will be promoted not just through individual checklists or bundles but through a deeper understanding of the varied demands of healthcare and the complex decisions required by patient, practitioner and manager. This will partly result from, and partly require, a fundamental change in attitudes to healthcare.

Resources

These resources offer practical suggestions for how executive and clinical leaders can begin to create the right environment for an active patient safety culture. 

 

 

Murray Anderson-Wallace is an independent strategy advisor working with the Clinical Human Factors Group.

Dr Ken Catchpole is senior post doctoral research scientist and human factors expert at the quality, reliability, safety and teamwork unit, Nuffield Department of Surgical Sciences, University of Oxford.