[image credit: HFES.org]
Healthcare is a notoriously convoluted system with many intangible issues dictated by deep-rooted cultures and significant power structures. Human factors is a discipline with the reputation of being vague, yet with tactical applications: validate this, make that safe, etc. At this year’s Human Factors and Ergonomics Society’s Health Care Symposium, the theme of “bridging the gap,” for me, meant bringing together our knowledge of complex healthcare problems in an attempt to find the most meaningful way to address those problems.
Our natural reaction to complex, large problems is to simplify them. At the symposium, I saw presentations that did just that: a presenter used multi-variate analysis to distill conversation weaknesses into clear cut themes, another used generalizing language without site-specific implications, and many others pulled frameworks of understanding from other disciplines to explain observed phenomena. But does this desire to simplify the healthcare landscape accurately reflect its reality? In this symposium, three big-picture (and very complex) issues came up frequently—compliance, obscurity, and fundamentalism—for which simple sweeping analyses could not be put in place.
During a panel discussion on challenges in home health care, Dr. Eric Dejonge of Washington Hospital Center said that the “biggest human factors challenge is getting people to take their medication.” Mary Brady of the FDA added that part of the reason why in-home treatment is so difficult is because patients in need of home healthcare don’t necessarily consider themselves sick, rather they view themselves as “aging in the home.”
Chronic illnesses, like heart disease and diabetes, which require sustained long-term care (i.e. treatment therapies, home assistance) are a big financial strain on the healthcare system (and on family caregivers). Remedied through medication and lifestyle adjustments, it can be difficult to get patients to fully comply with treatment because it brings into question their autonomy, and without many acute symptoms, they’ve become accustomed to a different quality of life.
Human factors professionals are crucial in highlighting significant patient-initiated barriers that impact the design and development of medical devices and applications. The essential message behind patient compliance is that just because something is designed to be safe and effective, doesn’t ensure it will change a patient’s likelihood to use/leverage it. However, because compliance is a well-known problem, we can begin to understand it and create solutions to approach it (accountability features, gaming mechanics to encourage participation, etc.)
Being such a large entity, the minutiae of everyday events in healthcare become lost or condensed into generalizations of “how the system works.” How can human factors attempt to lift this veil of obscurity and identify the real problems that need to be solved? One way of doing it is expanding our methodology toolkit.
In sociology, there is a field of study called ethnomethodology, which looks at large systems of structure that maintain societal order. Ethnomethodological studies uncover the real problem that exists in society, not just the problem that makes it into record-keeping. For example, what may be recorded at a hospital is the incidence of a particular illness, to which our natural inclination is to find a solution for that illness. Ethnomethodology attempts to examine the motivations behind how that illness became a recorded event in the first place.
Ken Catchpole of Cedars-Sinai Medical Center presented an example of how adverse events (recorded mistakes) become documented. In this process of documenting an adverse event, what doesn’t get captured is what he deems “the more important close-call.” That is, the event that could have become adverse. In a subtle way he references a need for ethnomethodology to understand the healthcare landscape. In this case, he suggests that we need to solve the “close call” episodes using our human factors expertise, and not simply the recorded adverse events.
No complex system, like healthcare, is complete without structures in place that allow it to operate. The key quality of these structures is having a hard line perspective on “what works” and a resistance to changing the status quo. This resistance is most visceral when introducing new technology into a clinical setting; however, it is also seen in the human-to-human relationships and interactions.
Dr. Lucian Leape of the Harvard School of Public Health talked about the individualism stronghold among doctors, which enables a culture of disrespect in clinical settings. Disrespect, he argues, is rampant and widely the norm. At the same time, clinical settings have evolved into teamwork-reliant systems. However doctors are trained to make executive decisions, trumping all other input streams, should they feel the need. The legacy of individualism in a teamwork setting makes other team members feel bad about their work, discredits their efforts, and leads to a breakdown in communication. It has been demonstrated that these seemingly small interpersonal issues have a greater impact, which can compromise patient safety.
HUMAN FACTORS IN HEALTHCARE: UNNERVINGLY VAGUE OR REFRESHINGLY OPEN?
“Bridging the gap” for me, meant bridging the gap between the obtuse landscape in which healthcare human factors specialists must operate, and the desire to have simple and actionable solutions. Dr. Leape, in his highly inspirational and eye-opening speech, also mentioned that as treatment and clinical environments have gotten safer, they have introduced layers of involvedness that impact healthcare professionals and therefore patients. As human factors specialists, we need to leverage our notoriously vague disciplinary standing and attempt to identify complex issues and weaknesses in the system, and solve them in the most impactful way (which may not be a design or development solution, for example). This symposium was a great first step in getting folks to reexamine the utility of human factors and what it means in this setting: rather than being unnervingly vague, it can be refreshingly open.