Vicente, Chapter 7
Management Matters: Building Learning Organizations
Reading this chapter made me think of the new job my sister recently took on. Her job is with Alberta Health Services and she oversees 'hazards, close calls, and adverse events' within the organization. I have been grilling her for details on how our local health region handles these issues.
Of course I told her that she had to read Vicente's book, which, but the way has become incredibly difficult to find as of late - the copy that I ended up buying for her is a discard from the Edmonton Public Library, via the States - it was the only one I could find (food stains and all!). As I was investigating Vicente videos, I came across the following video that clearly indicates that there is much room for improvement of technology in health care. One has to wonder when and with whom usability testing was done! Designers could have gathered a wealth of information simply from observing the users in this video.
Oh Shnocks! The state of healthcare technology in '09 from Healthcare Human Factors on Vimeo.
I was very interested to hear that Alberta Health Services (AHS) is in the process of rolling out a Provincial Patient Safety Approach. Initially, the purpose of the Approach is to standardize the way AHA reacts and follow-up on adverse events, close calls, and hazards. I was pleased to learn that the process of reporting adverse events, close calls, and hazards is confidential - with the reporter having the option to share with their supervisors or not. The reports are not anonymous as the reporter's name is required for two reasons: to provide follow-up information to the reporter, and to contact the reporter if additional details are required. In a later stage, all reports are 'de-identified' and no longer associated with a particular person. In this scenario, the potential for "Shame and Blame" has been eliminated. Echoing Vicente's thoughts, AHS explains that the Reporting and Learning System reports "are not used for employee performance issues. Literature from global patient safety experts verifies that hazards, close calls, and adverse events are largely the result of flaws in the system. Reporting helps identify where the system changes can support care providers. Identifying the holes or flaws in the system is essential to improving the safety of patients." At this time, it is employees of AHS who are able to submit reports, but in the future, volunteers, patients/clients, their family members and visitors may also have the ability to submit reports. The reporting system that AHS is using is based on a 'System' model of safety in which events are examined while focusing on the system processes and issues that contributed or could contribute to an adverse event. The focus is on "fixing systems issues rather than trying to 'fix' individuals". The systems model is based on the work of James Reason ("Grandfather of Patient Safety"). It seems that AHS is taking a step in the right direction.
Below is a graphic, from AHS, depicting the process flow for reporting events:
I was also interested to learn that AHS has three Human Factor Specialists in its employ - in fact, there is a symposium today with a focus on Human Factors -- I will be sure to grill my sister at the end of the day!
Key quotes form chapter 7:
"Organizational decisions shouldn't be based only on what we know about the physical world. They should also take into account what we know about human nature" (p. 188).
"A design can be well-tailored to the characteristics of the body, the mind and the team, but all that forethought can go down the drain if organizational considerations aren't also dealt with effectively" (p. 188).
"A technological system won't succeed unless sufficient attention is paid to organizational issues, such as how decisions about safety are made in the face of outside pressures" (p. 189).
And, sadly,
"Human aspects of the design of an organization are still not often viewed as an integral part of the design of technological systems" (p. 228).
James Reason Resources:
Books by James Reason
A short, video on Delivering Patient Safety:
First of all, sorry for the book.
ReplyDeleteAnd the video makes even me, a watcher, feel frustrated and want to kill someone. Some machines are unimaginably designed as if to test their users intelligence and everything. Like the microwave I bought at London Drugs with my friend. It has so many unnecessary buttons. And I can't master upon using it without refering to the manuals which I don't like doing. Hehe~ So I just try my luck according to the words printed on each button. After several loud beeping sound, I SUCCEEDED in just warming a bowl of orange juice! I was just glad I didn't break this bad boy. Gosh! How I miss the LG microwave oven in my home back in Beijing which has only two switches and which my parents and I have used it for more than 10 years!
And yeah, when it comes to hospital, doctors, operations, medicine and disease, we have numerous things to say, or I should say, complain about. These things are all related to our health and even precious life. It's just we hope those people and things to be better, if not perfect. However, what if we are them and they are us? Can we make them satisfied? As people who have contact with these people and experience with those things, we tend to be critic, thinking they did it on purpose. I think we should cut some slacks for those people and those things. In more harmonious environment, those people can make improvements.
Robin, I found your insights into the patient safety systems in AHS very reassuring. I have been an AHS employee and I am glad to see that AHS is taking a step in the right direction. :)
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