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Applying Ergonomics to Improve Care Quality and Safety in Hospitals

This article is reprinted with permission from The Ergonomics Report™, where it originally appeared on March 1, 2012.

Researchers in Israel developed and tested a new reporting system designed to collect ergonomics problem reports (the researchers used the terminology "human factors", which I will henceforth replace with "ergonomics", as the terms are interchangeable when considering the broad definition  of ergonomics — including physical, organizational and cognitive aspects). The problem reports are then used to build a database to be used as a guide for improving the quality of health care and patient safety.

The researchers begin their article, cited below, with a summary of the magnitude of the problem, noting that the true number of problems and errors in health care delivery are difficult to quantify. Interested readers may want to review other Ergoweb articles that touch on this issues, for example:

Previous researchers have identified certain topics as problematic in the hospital environment, including:

  • medication administration;
  • physical layout;
  • data recording and management;
  • work procedures; and
  • medical device design. 

The typical source for data collection in hospitals has been accident investigations, sometimes complemented by reporting systems of adverse events and incidents. Even with the growing awareness and focus on health care ergonomics, the authors suggest little progress has been made in reducing the overall number and frequency of errors, due in large part to ineffective data collection methods, which therefore reduces the amount and nature of the intelligence that could serve as a guide to root cause identification and improvement (my words, not the researchers). They identify the primary barriers surrounding the usefulness of current reporting methods as including:

  1. low frequency of reporting;
  2. memory and report biases;
  3. absence of comparative data (e.g., is the error rate low when compared to the frequency of the activity being performed?);
  4. hindsight bias.

For example, researchers estimate that as little as 5% of all errors are ever reported, and 90% of errors that actually cause harm are never reported. They cite liability concerns and ineffective reporting systems as major contributors to this problem. Some researchers and practitioners have been able to improve reporting and problem solving by instituting reporting systems that include "non-routine events" (NREs), which include "any event that is perceived by care providers or skilled observers to be unusual, out of the ordinary, or atypical." While NREs can be a significant improvement over accident reports, they are limited in that they may include non-ergonomics related incidents, they require the involvement of interviewers and observers, and they may not capture continuing and repeating problems, essentially missing impaired efficiencies and safety problems that have become routine.

In conclusion, current reporting systems are limited in their effectiveness, which therefore limits the knowledge base necessary to properly address and reduce hospital errors and other adverse ergonomics incidents. The researchers therefore set out to develop and validate an improved ergonomics-related problem reporting system utilizing a three-stage process.

Stage 1: Reporting Form Development

Two hospitals participated in the study, and recognizing that each hospital had their own organizational structure and management style, the researchers applied a macroergonomic process (my words, not theirs), first securing the understanding and commitment of senior management to follow-through with the study and it's findings. With commitments from both institutions, the team:

  1. performed a systematic analysis of the daily work activities and routines to map the major ergonomics aspects associated with daily clinical staff work; and 
  2. develop forms to report relevant problems, difficulties and hazards.

Interested readers are directed to the original research article, cited below, for details concerning the development and justification of the forms. The final forms were directed at what they found as the five main ergonomics work-related problem areas:

  1. work procedures and structure;
  2. physical space and layout;
  3. medication administration;
  4. equipment and instruments; and
  5. reporting and recording.

The final version consisted of a single page for each ergonomics-related problem area and required only a few minutes to complete.

Stage 2: Collection of Reports in Actual Hospital Wards

An orthopedic ward, an internal medicine ward, and two gynecology wards participated in the study (115 beds, 81 nurses, 50 physicians). A 90 minute introductory training session was provided at the study kick-off, and included nursing and physician staff, as well as a senior management representative. Participants were instructed to use the forms ad lib to report difficulties and problems in their daily work. The participants were free to identify themselves on each report, or remain anonymous. Reports were then collected for a 12 week period.

Following the reporting period, the researchers utilized a three-member ergonomics research team to review each form and categorize them, which produced three groups of generalized problem categories:

  1. general problem types;
  2. specific (local) problems; and
  3. problems unrelated to ergonomics.

Their macroergonomic approach yielded promising results.

  • Prior to their study, the four participating wards combined reported a total of 200 incidents, over a five year period, through the hospitals' existing mandatory reporting system. The new process produced 359 problem reports in just 12 weeks.
  • Previous to the new method, all incident reports were filled exclusively by nurses. With the new reporting method, 30% of the reports were filled by doctors, 21% of those anonymously. These rates corresponded well with their relative time and share of the ward activities.
  • Participation was high, and the dominant categories and types of reported problems differed from ward to ward, indicating the reporting system was sensitive to different environments and systems.

Stage 3: Validation Studies of Reported Problems

Each ward was validated separately, though one of the ward validation studies was discontinued because the ward moved to a new facility, which changed the daily work environment and conditions. The researchers selected the most frequent problem topic identified by the reporting process in each ward. A thorough validation approach was devised for each ward, and utilized sampling of actual data for use in comparison with the reported incidents. For example, in the internal medicine ward, senior internists identified the frequency of monitoring required for nine indices for monitoring patients' medical status (e.g., heart rate, blood pressure, etc.). Actual patient data (names and personal identifiers removed) were then reviewed and statistically compared with a control group and the participating ward group to verify the problem reports were sensitive enough to identify improper monitoring frequency. Interested readers are referred to the original research article for extensive ward-by-ward validation details.

Study Conclusion

The researchers report that their work has developed an effective two-step process that improves ergonomics-related root-cause problem identification, which can then lead to effective improvement (my words, not theirs). They note improvements over existing problem identification systems, including:

  • increased care giver participation, including doctors;
  • sensitivity to repeated or continuing difficulties in care delivery, not just specific or unusual incidents;
  • a proactive approach, verses the typically reactive approach existing reporting systems produce;
  • economical and efficient use of ergonomics professionals, in that they are able to quickly and effectively focus on pertinent issues;
  • avoidance of blame and accountability issues;
  • increased awareness of ergonomics-related concerns, leading to self-initiated problem identification and solutions by medical staff.

What this Contributes to the Practice of Ergonomics

Among the applicable lessons I learned or was reminded of while reviewing this study:

  • ergonomics can produce measurable and significant gains by improving business intelligence;
  • ergonomics plays a large and critical role in reducing medical errors and improving health care delivery;
  • there is much more to ergonomics than injury reduction, including improvements in work and service/product quality, and improvements in process efficiency;
  • ergonomics improves the patient experience, as well as care giver experience, and contributes substantially to business/organizational purpose and success;
  • effective ergonomics involves a systematic process approach;
  • macroergonomic techniques, such as involving and gaining commitment from all participants, from top management to employee level, make improvements more likely and more effective; 
  • well implemented ergonomics methods increase responsibility and accountability among team members, an essential ingredient for sustainable organizations; and
  • hospitals that "get it" are far better and more likely to be successful than those that don't (e.g., see Success and Failure: An Experience with Healthcare Ergonomics).

Reference

Soudry Milwidsky, Rivka-Rita Feigin, Shimon Pollack, Itay Maza, Zaher S. Azzam, Hanna Admi and Michael, Human Factors−Focused Reporting System for Improving Care Quality and Safety in Hospital Wards, Human Factors: The Journal of the Human Factors and Ergonomics Society, published online 22 February 2012. DOI: 10.1177/0018720811434767

The online version of this article can be found at http://hfs.sagepub.com/content/early/2012/02/21/0018720811434767

This article originally appeared in The Ergonomics Report™ on 2012-03-01.