Simple forms that matter: Aa cognitive human factors perspective
Daniel Gopher
Research Center for Work Safety and Human Factors Engineering Technion
The dilemmas of modern health care
However
Modern health care is powerful and improving exponentially.
It is technology rich, information rich, and requires collaborative team work.
Consequently
Nonetheless !!!
Health care is expensive. Health care is more error prone. Technology and improved care should be available for all. The call of democracy.
How hazardous is health care?
REGULATED DANGEROUS (>1/1000) Health Care Driving ULTRA-SAFE (<1/100K)
100,000
10,000
Total lives lost per year
1,000
100
10
Mountain Climbing Bungee Jumping
Chartered Flights Chemical Manufacturing
10,000 100,000
Scheduled Airlines European Railroads Nuclear Power
1,000,000 10,000,000
1 1 10 100 1,000
Number of encounters for each fatality Note: both dimensions are logarithmic
The US Healthcare Quality Paradox
Highly trained practioners Wide spread state of the art technology Health expenditure 15% of the GNP Unparalleled biomedical research Medical errors, overuse, underuse and misuse common, serious and systemic in nature, largely preventable
BUT DESPITE THIS:
Cause of paradox Doctors and nurses work in a hostile environment
Big investments made in direct medial interventions, little or no investment in the design of the overall system
Complex and user unfriendly technology. Undeveloped and incompatible information recording and information transfer technologies. Absent, ill designed, uncoordinated and poorly managed work procedures.
The change of these is our challenge
What is the “system”? An Example of a Surgical
Procedure
1 2 3 4 5 6 7 8 9
10
Head surgeon surgeon Scrub nurse anestesiologist running nurse sanitarian reception nurse Communication nurse Coordination center nurse ward nurse stretcher bearer recovery room nurse
11 12
A Human Factors view of the surgical process
A relay competition
Research Center for Work Safety and Human Factors
A Cognitive User Centered Redesign of a Radiotherapy Chart
R. Sela, Y. Auerbach, Z. Straucher, M. Rogachov, O. Klimer, D. Gopher Research Center for Work Safety and Human Engineering, Technion, Israel Institute of Technology, Israel R. Bar-Deroma, R. Carmi, A. Kuten, S. Pollack, Rambam Medical Center, Haifa, Israel
Following several mishaps and a serious accident, the management of the Rambam Medical Center has asked the Research Center for Work Safety and Human Engineering at the Technion to conduct a human factors and safety analysis of the hospital Radiotherapy unit.
The Radiotherapy Chart
A paper form used during all phases of a radiotherapy treatment process. Used for:
Recording of treatment orders and following their execution. Documentation of medical information. Quality assurance tests.
It is the only comprehensive and integrative record of the information about a patient in the unit (2000 new patients per year; a 3 weeks – 3 months procedure). Serves all staff members taking part in the treatment procedure (30 users).
Staff members – users of the chart
Physicians Physicists
Nurses
30 Users
Dosimetrists Technicians
Dietitian
Medical Secretary
Social worker
Method
1.
General analysis: mapping of the general work procedures Interviews with staff members. Observations of therapy phases. Focused analysis: assessment of cognitive usability aspects of the existing chart. Redesign:
Content: What information items should be included? Format: How should this information be presented for all users?
2. 3.
Main Outcomes of the Analysis
The chart is the major reference and communication tool of the multi-disciplinary radiotherapy team – Patient present status and history.
The chart does not support correct, safe and none ambiguous work procedures.
Design features of the chart pose great difficulties in daily work and increase the probability of adverse events.
Existing Chart
Major cognitive problems in the existing chart And design solutions in the new chart
Redesigned Chart
Problem: Memory
and Search Load
50 of 120 (42%) required data fields were not present in the existing chart.
Users must:
Writers: remember what information is required and add it. Readers: search for and locate this information. Risks: Critical information is not inserted, not attended to or hard to retrieve. Outcome !!! Erroneous execution of treatment orders.
Solution to: Memory
Constructed data fields:
and Search Load
Identification of all information required by each user. Inserting new data fields. Determine their proper format and location.
Problem: Ambiguity
of blank data fields
Wedge
Not Needed
Needed BUT forgotten to be specified
(unfilled)
This ambiguity may lead to incorrect execution of treatment orders. Potential radiation overdose of up to 40%.
Solution to: Ambiguity
of blank data fields
1. Simple and immediate: A required ‘Not Needed’ indication.
Wedge
_ 20%
Needed Not Needed STOP and Check orders
Solution for: Ambiguity
of unfilled data fields
2. Redesigned Chart: Constructed fields for all possible answers
4 Categories of improvements
1.Complete and unambiguous presentation of information
Redesigned Chart Old Chart
2. Readability and organization of the information
Redesigned Chart
Functional Workflow
Old Chart
Use of graphics and color
2. Readability and organization of the information
Redesigned Chart
Location and Visibility
(continued)
Old Chart
Language
3. Process control and revalidation aids
Redesigned Chart Old Chart
4. Modularity and adjustability
Redesigned Chart Old Chart
The new patient file