How can Human-Systems Integration Support a Safety Culture? An Overview of Human-Systems Integration: Implications for Quality and Safety in the Healthcare 1 5 th Annual Middle Eastern Forum on Quality and Safety in Healthcare Hamad Medical Corporation (HMC) & Institute for Healthcare Improvement Doha, Qatar Saturday May 6, 2017 Dr. Najmedin Meshkati Professor, Department of Civil/Environmental Engineering Professor, Department of Industrial & Systems Engineering Professor, School of International Relations University of Southern California & Commissionaire, The Joint Commission Email: [email protected]
Transcript
How can Human-Systems Integration Support a Safety
Culture?
An Overview of Human-Systems Integration:
Implications for Quality and Safety in the Healthcare
1
5th Annual Middle Eastern Forum on Quality and Safety in Healthcare
Hamad Medical Corporation (HMC) & Institute for Healthcare Improvement
Doha, Qatar
Saturday May 6, 2017
Dr. Najmedin MeshkatiProfessor, Department of Civil/Environmental Engineering
Professor, Department of Industrial & Systems Engineering
• Introduction/My story – Cross-cutting/common human factors and safety culture issues
• Human-Machine System (HMS) and Human-Machine Interactions
• My Premises re major subsystems of a complex technological system, e.g., healthcare–The “HOT” Model
• An example of “design-induced error”
• The role of cultural factors
• Why safety culture is important/vital, what is it, what are its roles in patient safety
• High Reliability Organization (HRO) and healthcare
• Conclusion – Closing Remarks
2
My story…Last 30 years of working directly with and experience with:
• Aviation
• Nuclear power
• Offshore Drilling
• Petrochemical
• Refining
• Oil & Gas Pipeline
• Railroad
• Maritime
• Coal Mining
And recently (last 15+ years) with Health Care industries
March 28,
1979
Three Mile
Island
December
3, 1984
April 26,
1986
March 23,
2005
April 20,
2010
March 11,
2011
Chernobyl
Bhopal
BP
Deepwater
Horizon
BP
Refinery
Fukushima
My life story…..
Medical Systems
USC Keck Hospital2014
7
An Example of
Human-Machine System
Human-Machine Interactions
Human-Machine System
Operator A
Operator B
MACHINE
Interface Level MachineHuman
Input Output
System Z
System X System Y
Primary
Interactions
Secondary
Interactions
Situational
awareness
12
A Fundamental Issue(My Premise)
Safety and Reliability of Complex
System
The ‘HOT’ ModelMajor Subsystems of a Complex Technological System
(e.g., a nuclear power plant, refinery, hospital)
13
Human
Organization
Technology
Volume of Output
Interactive
Effect
14
Human
Organization
Technology
Volume of Output
Interactive
Effect
Human Error
A Fundamental Issue
“Human error can be considered
as either human-machine or
human-task mismatches.”
Professor Jens Rasmussen
Los Angeles, 1992
System-induced or Design-induced human errors can be considered
as (or caused by the) following types of mismatches:
- Human-machine;
- Human-task; and/or
- Human-organization
16
17
Wrong-site Surgery
18
Source: The New York Times, “So, the Tumor Is on the Left, Right? Seeking Ways to
Reduce Operating Room Errors”, Sunday, April 1, 2001, P. 23
An Example of
Design-Induced Error and
System’s Failure
A B C D
A
BC
DA B D C
BD
A C
B A D C
BD
A C
A B C D
BD
A C
I II
III IV
A B C D
A
BC
DA B D C
BD
A C
B A D C
BD
A C
A B C D
BD
A C
I II
III IV
Number of errors
Design out of 1200 trials
I 0
II 76
III 116
IV 129Source: Chapanis & Lindenbaum, 1959.
Human Factors, Workplace Design, &
System Safety/Reliability
“The Human Error Probability (HEP) will be reduced by factors of 2 to
10 if the workstation (display and controls) are improved by the
incorporation of standard human engineering concepts”(Swain and Guttmann, 1983, p.11-5)
From: Swain, A.D. and Guttmann, H.E. (1983, June). Handbook of Human Reliability Analysis with Emphasis
on Nuclear Power Plant Applications. Final Report (NUREG/CR-1278). Washington, D.C.: U.S. Nuclear
Regulatory Commission.
Personal Observations on
the role of Cultural Factors in
Human-Machine/Technology
Interactions
&
Safety
Culture, Facts and Theories
Facts are not pure and unsullied bits of information; culture also influences what we see and how we see it. Theories, moreover, are not inexorable inductions from facts. The most creative theories are often imaginative visions imposed upon facts; the source of imagination is also strongly cultural.
(The late) Professor Stephen Jay Gould, renowned Harvard University professor of geology, biology, and the history of science (The Mismeasureof Man, 1981, p. 22).
March 28,
1979
Three Mile
Island
December
3, 1984
April 26,
1986
March 23,
2005
April 20,
2010March 11,
2011
Chernobyl
Bhopal
BP
Deepwater
Horizon
BP
Refinery
Fukushima
My life story + Aviation accidents (with cultural issues)
Avianca,
1990
Korean Air 801,
1997
Überlingen,
2002
Asiana 214,
2013Tenerife,
1977
National Culture Implicated as a
Contributing Factor to 5 Severe Accidents
• Tenerif - Runway Incursion – Canary Island,
Sprain - 1977 (583 fatalities)
• Avianca 052 – Crash - New York – 1990 (73
fatalities)
• Korean Air 801 – Crash - Guam – 1997 (228
fatalities)
• The Überlingen mid-air collision –
Switzerland – 2002 (71 fatalities)
• Asiana 214 – Crash - San Francisco -2013 (3
fatalities)
International Civil Aviation Organization
Journal(Oct 1996)
Revista Tecnia del ANPAC – (2000)(Nazionale Piloti Aviazione Commerciale)
National Commercial Pilots Association
Italy
The Cultural Context of Nuclear Safety
Culture:
A Conceptual Model and Field Study(1999)
Australian Aviation, March 2014Writer: Geoffrey Thomas
“Asiana crash shows continued need for vigilance against CRM & cultural issues”
“The number stands at 42. To be more precise, SIA currently employ pilots from 42
different countries” (Email from Capt …September 22, 2003)
National Culture
Corporate Culture
Safety Culture
National, Corporate, & Safety Culture(s)
What is Safety Culture and why it is so important
Why safety culture is so critical/vital?
Safety Culture as a Root-Cause of a System’s
Common Mode Failure
• Because of their diversity and redundancies, the defense-in-depth will be widely distributed throughout the system.
• As such, they are only collectively vulnerable to something that is equally widespread. The most likely candidate is safety culture.
• It can affect all elements in a system for good or ill.
Professor James Reason, A Life in Error, 2013, Page 81
What is Safety Culture?
US Nuclear Regulatory Agency’s (US NRC) Definition of
Safety Culture
“The core values and behaviors resulting from a collective commitment
by leaders and individuals to emphasize safety over competing goals to
ensure protection of people and the environment.” (SECY-11-0005,
January 5. 2011)
The USNRC’s Policy Statement on Safety Culture
(SECY-11-0005, January 5. 2011)
Nine “traits of positive safety culture”
1) Leadership Safety Values and Actions - Leaders demonstrate a commitment to
safety in their decisions and behaviors;
2) Problem Identification and Resolution - Issues potentially impacting safety
are promptly identified, fully evaluated, and promptly addressed and corrected
commensurate with their significance;
3) Personal Accountability - All individuals take personal responsibility for
safety;
The USNRC’s Policy Statement on Safety Culture
(SECY-11-0005, January 5. 2011)
Nine “traits of positive safety culture”
4) Work Processes - The process of planning and controlling work activities is
implemented so that safety is maintained;
5) Continuous Learning - Opportunities to learn about ways to ensure safety are
sought out and implemented;
6) Environment for Raising Concerns - A safety conscious work environment
(SCWE) is maintained where personnel feel free to raise safety concerns
without fear of retaliation, intimidation, harassment, or discrimination;
The USNRC’s Policy Statement on Safety Culture
(SECY-11-0005, January 5. 2011)
Nine “traits of positive safety culture”
7) Effective Safety Communication - Communications maintain a focus on safety;
8) Respectful Work Environment - Trust and respect permeate the organization; and
9) Questioning Attitude - Individuals avoid complacency and continuously challenge
existing conditions and activities in order to identify discrepancies that might result
in error or inappropriate action.
Leadership and Safety Culture
A few words about
US Nuclear Regulatory Agency (US NRC)
and Institute of Nuclear Power Operations (INPO) Similar
Definition of
Safety Culture
• “The core values and behaviors resulting from a collective
commitment by leaders and individuals to emphasize safety over
competing goals to ensure protection of people and the environment.”
(Safety Culture Policy Statement, Federal Register, June 14, 2011)
• “For the commercial nuclear power industry, nuclear safety remains
the overriding priority” (INPO 12-012, Traits of a Healthy Nuclear
Safety Culture, April 2013)
INPO’s
Traits of a Healthy Nuclear Safety Culture
48
INPO (p.6)
“Nuclear safety culture is a leadership responsibility. Experience
has shown that leaders in organizations with a healthy safety
culture foster safety culture through activities such as the
following:
• Leaders reinforce safety culture at every opportunity. The
health of safety culture is not taken for granted.
INPO (p.6 &7)
• Leaders frequently measure the health of safety culture with a focus on
trends rather than absolute values.
• Leaders communicate what constitutes a healthy safety culture and
ensure everyone understands his or her role in its promotion.
• Leaders recognize that safety culture is not all or nothing but is, rather,
constantly moving along a continuum. As a result, there is a comfort in
discussing safety culture within the organization as well as with outside
Source: US Department of Energy (DOE) (2012). Accident and Operational Safety Analysis. Volume I: Accident Analysis Techniques. US DOE, P1-32
There will always be a performance gap between “work-as-planned” and “work-as-done”
work performance gap (ΔWg) because of the variability in the execution of every human
activity
Fatigue and Human Performance
83
NRC Sources
Fatigue and Human Error Probability (HEP)
• Across a broad range of industries, studies concerning extended work hours suggest that fatigue-induced personnel impairment can increase human error probabilities by a factor of more than 2 to 3 times
• Source: Hanecke, et al., 1998; Colquhoun, et al., 1996; Akerstedt, 1995; U.S. DOT, 49 CFR Parts 350, et al., Proposed Rule, May 2, 2000, 65 FR 25544.
84
85
…fatigue-induced personnel impairment can increase human error probabilities by a factor of more than 2 to 3 times
…“The Human Error Probability (HEP) will be reduced by factors of 2 to 10 if the workstation (display and controls) are improved by the incorporation of standard human engineering concepts”
Guess what will be the error probability of a fatigued operator/aviator/mariner working with a badly designed workstation?
Fatigue’s Effects on
on
HOT
86
87
Human
Organization
Technology
Volume of Output
Fatigue
Effect
Fatigue
Effect
88
89
90
An Example of
Human-Machine System
Human-Task Interactions
91
Operator
Balanced Human-Machine System
(Human-Task Interactions)
Equilibrium
From Meshkati (1983)
Interaction
sMachineJob (Task Demands)
92
Operator(Characteristics)
Job(Characteristics)
An Example: The Balanced WorkloadEquilibrium
Examples of Individual Differences-related Factors
• Skill, Knowledge, Attributes• Complexity Orientation• Tolerance for Uncertainty and Incongruity• Decision Styles (IBP)• Personality Variables
Examples of Job-related Factors• Task Demands• Amount and Complexity of Information• Time Pressure and Pace• Importance of Job’s (Performance)
Consequences• Structure, Autonomy & Decision Latitude• Social Needs and Interactions• Organizational Variables (Culture)
