Health Service Focus

Human factors in practice

Dr Lauren Morgan, lecturer and researcher in human factors and ergonomics at the Nuffield Department of Surgical Sciences at the University of Oxford, and a member of the Chartered Institute of Ergonomics and Human Factors, talks about the small but growing impact of her profession on the NHS.

Dr Lauren Morgan is thought to be the first human factors professional in the NHS to work directly within a trust on core system change projects. 

She told us: “It’s completely new. Addenbrooke’s in Cambridge has employed a human factors practitioner, but that’s the only other trust that has anyone working within the trust on projects, and I think that person is doing more training – whereas I’m actually involved in the systems change of the hospital.” 

Human factors is the scientific discipline concerned with the interactions between the human elements and the other elements of a system. That can include tools, technology, the environment in which people work, and the nature of the organisation itself. Morgan explained: “It’s about how each of those elements of the system either enables us to do our jobs, or are barriers to us doing our job well. 

“The thing that human factors does is consider all the humans within that system. Clinical staff are obviously one of the human elements, but healthcare is quite unique in that we have these other human elements – the patients – who often get missed when you’re looking at systemic changes within healthcare. That’s where human factors [practitioners] can be really useful – to bring their needs and issues and abilities to the fore. 

“They can look at the patients in terms of all of the different aspects of their need, and can consider that within the wider healthcare system. They can consider how the technology within the healthcare system (or lack thereof) can enable patients to receive the best care and best interaction that they might possibly want and how the environment is set up. That’s not just for a patient as we might imagine a patient, but actually the range of patients who we will see in our healthcare system – which means as wide a range as the general population.” 

That means, she said, doing more modelling to understand complex needs, from reduced mobility to sight loss. “Unless you acknowledge those in the design of your new system or your current system, you are going to exclude a large proportion of your patient population,” Morgan said. 

Human factors in practice 

The most recent project for Morgan and her team at Oxford University Hospitals NHS FT (OUH) has focused on new technology and processes to digitise the documentation of patients’ vital signs, known as SEND (System for Electronic Notes Documentation). 

But they did not approach it like a traditional IT project. Morgan explained: “We wanted to understand, before going near the technology, what it is about the current way that task is completed that allows the nurses and doctors to give the best care they possibly can, and what it is that currently makes things difficult for them. 

“We found that because it’s a very routine task, it actually facilitates a lot of the communication between the nurse and the patient, as part of their care. So what we don’t want to do is remove any aspect of that task away from the bedside, because that would be detrimental to that communication.  

“We also observed the amount of nursing time wasted by nurses trying to collect pieces of equipment. That took them away from essential patient care and from having the time to talk to the patient. 

“As part of our new design, then, we were able to keep all the pieces required to complete the task together, and make sure that the electronic tool was faster than it was to complete the normal task with paper, so that we released time for the nurse to care for the patient.” 

Faster and safer care 

The project is now rolled out at three of OUH’s four hospitals, and will be trust-wide soon, once work is finished at the John Radcliffe Hospital. In total, 300 Dell tablets will be deployed once the SEND roll-out finishes this summer 2016, at a cost of £145,440. Since SEND was introduced, more than 2 million patient observations have been recorded for about 12,000 patients using 140 tablets, with an average of sixtablets deployed to each ward.

Funding for the £1.1m project originally came from the ‘Safer Hospitals, Safer Wards’ NHS fund to improve patient safety. Now, when nurses take readings of a patients’ vital signs, they input that information straight into a tablet device, which calculates and immediately displays an Early Warning Score, helping to decide where medical intervention is needed. 

The research underpinning this system was funded by the Research Council UK’s Digital Economy Programme, led by the EPSRC (Engineering and Physical Sciences Research Council). Its translation onto the ward was supported by the Oxford Biomedical Research Centre. Professor Lionel Tarassenko from the University of Oxford’s Institute of Biomedical Engineering has been leading the project, working in close collaboration with Dr Peter Watkinson and Dr Tim Bonnici, among others. 

Transformation 

Morgan’s team helped ensure the design, development and implementation of this major change project took account of human factors the whole way through. She said: “The benefit that human factors has given us is that we have had no calls to the helpdesk. We’ve got fantastic user feedback on how easy the system is to use and how fast it is to use. It’s just transformed the way that the trust approaches technology projects now, because we were able to do the systematic evaluation upfront and predict where the risks might be. That allowed us to seamlessly integrate this piece of technology into the trust. 

“And so now what we want to do is, because we know this is really for clinicians to use, we want to build the ‘patient side’. There’s a lot of patients within the NHS who are managing long-term conditions and taking their vital signs outside of the hospital setting. It would be fantastic if that data from outside the hospital could be integrated into the data that the clinicians see when the patients are in hospital. 

“That could be used to, say, bring forward a clinic appointment if the clinicians can see the patient’s temperature is getting a bit increased, or to say ‘well, we don’t need to see you this week, maybe we can just see you next week’. So there could be efficiency savings for the NHS there as well. 

“We’ve been talking to patients about developing this, though it is very much in the early developmental stages. In the same way we observed how the clinicians interacted with the vital signs, we need to do the same piece of work to understand how patients interact with them, and how they’d like that to work for them. The worst thing is to have things designed ‘for you’, not ‘with you’.” 

Another project is linked to delayed transfers of care – which, as our news story on page 8 makes clear, is one of the biggest problems for the NHS. Using a similar systematic risk reduction process and human factors input could be transformative, Morgan said. 

Resources 

Morgan’s team and its work have attracted notice, and it seems like the NHS is waking up to the potential value of a human factors perspective. Her team has tripled in size in just a couple of years. 

“The main demand at the moment is still on training clinicians,” she said. “But I feel the benefit is in having practitioners like me sat alongside clinicians, understanding change and redesigning systems for them. That’s more what my role is, though I’m employed by the university. 

“I’ve not had a single clinician or manager or any other allied health professional who’s come to any of the training courses who’s said it wasn’t beneficial.” 

She said patient safety failures are usually multi-factorial and happen when systems fall down. “It’s very rarely the human at the blunt end who is to blame for any of this – they just happen to be in the wrong place at the wrong time,” she explained. “So, if we can help them to know how to look for risk factors, and understand them, it can help them deal with it if an incident does arise, but it can also help them design their system so that risk isn’t there for the patient. That is a safer, better position to be in.” 

The human factors work that is happening in healthcare, however, is overwhelmingly via research projects and academic input, rather than via the NHS itself. “Because it’s not a recognised part of the healthcare system, it’s not funded through any normal means within the hospital,” Morgan told us. “The hospitals are expected to have assurance teams, they’re expected to have HR, but there’s no expectation that they will have anyone with human factors expertise.” 

There are signs of change. For example, the John Radcliffe has recently been advertising for a new surgeon post with the requirements for the role specifically including human factors skills. Morgan called that a “step change” for the NHS, and added: “I don’t think it’s any surprise that that’s the unit I’ve worked most closely with. They are recognising what benefits this has for clinicians. 

“But while the medical director knows what human factors is, has read plenty of books on it and understands where we are, and calls me or our team to ask us to help on different things, the fact is we’re still a research team working within a university. We’re not employed by the hospital, and I think we’re a ways off from that yet.”

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