Quality Rounds
Human Interest
By Jeanne Mettner
A cognitive psychologist helps design patient safety systems that factor in human beings’ fortitude and frailties.
Kathleen Harder, Ph.D., has built her career around that unpredictable variable over which no designer has control: the human being.
Harder, a cognitive psychologist at the University of Minnesota, is an expert in human factors research and design, the focus of which is creating systems, work processes, and technologies that facilitate better human performance at work and elsewhere. Typically, human factors experts work with government or industry. Harder is one of the first to work with health care systems.
Harder got her start in the mid-1990s, looking for ways to make us safer on the road. Working with the Minnesota Department of Transportation and other organizations, she studied drivers’ acceptance of delays at metered ramps on highways, the value of travel-time information, and the effect of rumble strips and other features on driver performance. By 2000, she began shifting her focus from traffic safety to patient safety. “Working in health care was one of those areas that I had always been interested in,” she says.
But earning the respect of those who set health care policy was not easy. “I couldn’t just walk into a hospital or clinic and say, ‘Hey, I want to work with you guys,’ and expect a favorable reaction. In reality, it was more like, ‘Well, what do you know? You’re not a clinician,’” she recalls.
Within months, however, Harder began convincing them that her outsider status was an asset. “One of the chief selling points was that I could bring in an outsider’s perspective. People are carrying out their work the way they do because that’s how they know it best. They don’t have the time or frankly often the capacity to step back and ask, What can we do to make the whole system better? But I could come in with fresh eyes and ask questions,” she explains.
Harder demonstrated that ability in 2001 when the Institute for Clinical Systems Improvement (ICSI) invited her to speak about the human factors field. For her presentation, she took one of their protocols on drug administration and illustrated ways to make it better.
Harder captured the attention of Allison Page, M.S., M.H.A., chief safety officer for Fairview Health Services. Page asked Harder to help solve a problem in their interventional MRI unit—a surgical suite with an MRI machine that can be used for imaging during procedures.
Controlling equipment and other items that are magnetic can be a challenge. On several occasions, staff had inadvertently brought ferrous metals into the suite—a pen in a pocket, a piece of jewelry on someone’s wrist or around their neck. On one occasion, a piece of equipment flew across the room and attached itself to the outer casing of the MRI. Although the incident did not cause injury or harm, the administration wanted to make sure it never happened again. After working together for several months, Harder and the MRI team came up with specific solutions to keep metals at bay—mandatory check-in stations, lines of demarcation around the MRI unit indicating where ferrous metals were prohibited, even pocketless scrubs. Since implementing the changes in 2003, the interventional MRI unit has had no accidents involving metals.
Page says for the most part, health care safety involves “good, smart people doing the right thing all the time.” But she notes that sometimes systems need to take over. “The human factors part of the project helped us see that we can do a better job if we put systems in place that can prevent the downsides of normal human behavior from compromising safety,” she says.
A Different Type of Design
Harder very much considers human factors research to be design work. “My approach is somewhat similar to what designers or architects do, but instead of designing clothing or buildings, we are designing information,” she says. Today, she heads up the Center for Human Factors Systems Research and Design, which was created last year as part of the University of Minnesota’s newly established College of Design. The purpose of the center is to help organizations solve problems involving policies and systems by designing solutions that account for humans’ strengths and limitations.
Although the center is new, Harder’s approach to human factors analysis has not changed since she began working in the field. Her forte as a cognitive psychologist is to create order from chaos, and accomplishing that starts with being what she describes as a “fly on the wall.”
While working on a project to reduce the number of foreign objects left in patients after surgery, which she completed in mid-2004 for the University of Minnesota Medical Center, Fairview, Harder and John Bloomfield, Ph.D., a fellow cognitive psychologist, sat in on at least a dozen surgeries. They followed the case from the time patients entered the surgical suite until they were taken to recovery. “We observe and we observe and we observe,” Harder says. “We get a rich layer of information that comes from being there in the thick of it, hearing the sounds, seeing the nonverbals. We take copious notes, and we will observe surgery after surgery until we get what we call converging evidence—repeated patterns or behaviors that indicate to us that we have conducted a thorough investigation.”
After the observation period, Harder and Bloomfield interviewed surgeons, nurses, anesthesiologists, and surgical technologists about what was good and bad about the processes used in the OR. The results surprised administrators. “One thing we quickly identified was that even with the processes and procedures we had in place, some staff members were deciding, ‘Well, that’s silly, I’m just not going to follow it,’” says Carol Hamlin, R.N., M.S., director of departmental performance for perioperative services. “We also learned that staff sometimes did not abide by these previous policies because they were so poorly written.”
In their formal presentation to Fairview administrators, Harder recommended a number of changes: Count the sponges and sharps before the patient enters the OR to minimize distractions. The circulating nurse and surgical technologist conducting the count should look at the individual items and do the count together. Encourage staff to call a safety time out if someone or something in the OR compromises the count. If the count is interrupted, do it again. Mark the count on a whiteboard with preformatted categories on the OR wall so that more than one person can check the count’s accuracy. Before closing the patient, make sure that all counts are correct. Once the group approved the recommendations, Harder and Bloomfield wrote a new policy that was easy to understand.
Between 2003 and mid-2004, the University of Minnesota Medical Center, Fairview, reported nine instances in which foreign objects were retained as a result of improper counting during surgery. Since implementing Harder’s system more than three years ago, the hospital has had no additional events. (Harder also assisted ICSI in its development of a protocol for preventing retention of foreign objects.)
Within the same 18-month period from 2003 to 2004, the University of Minnesota Medical Center, Fairview, had also discovered six episodes in which specimens were mismanaged during surgery. “Some specimens were mislabeled, some were lost altogether,” recalls Hamlin. Harder reworked the specimen-management forms to make them less confusing and then revised policy to tighten the chain of custody for specimens. “The new policy ensures that checks are in place so that no specimen is left sitting out unattended at the OR desk,” Hamlin explains. Since implementing the changes in 2005, only one lost specimen has been reported.
Harder also helped Fairview develop a better process for ordering and administering blood transfusions. Before Harder was called in, physicians were writing orders for blood on patient charts. At times, it was unclear whether an order required that a blood component be irradiated, which helps prevent transfusion-associated graft-versus-host disease in immunocompromised patients. Harder and Bloomfield created a new order form that is used at the time of the initial order and the transfusion. The form requires physicians to indicate in two separate areas whether the blood component should be irradiated.
“What seemed redundant [placing the order request in two different areas on the form] was actually an incredibly effective way to create an intentional thought process for the physician,” says Chris Senn, C.L.S., laboratory manager in the acute care laboratory at the University of Minnesota Medical Center, Fairview. “There are still times when the information provided on those two parts of the form are contradictory, but the blood bank can catch it right away and get further clarification from the physician so the patient gets the correct blood component.”
The team is now working with Harder to create an identification system in which a bar code on the ordered blood will match one on the patient’s wrist band.
Climate for Change
Since 2003, when state lawmakers enacted legislation that mandated hospitals report certain serious adverse health events—the so-called “never events”—and since 2005, when the Minnesota Department of Health released its first adverse events report, there’s been a new openness about errors and mishaps in medicine. Ask any department head how many specimens were mishandled in the past year, and he or she will be quick not only to provide the number but also to point out the potential reasons for the mishap and what was done to rectify the situation. “Hospitals and administrators here really understand that they can’t reach a level of improvement until they acknowledge openly that there are problems to conquer,” Harder says.
Such transparency has made health care organizations more appreciative of the skills human factors experts offer. Health care systems now make up about 80 percent of Harder’s client base.
“The No. 1 advantage of having human factors science integrated into health care is that it’s teaching us to see with different eyes,” Page says. “I predict it will be part of training for clinicians and administrators in health care, just as biology and pharmacology and accounting are now.” MM
Jeanne Mettner is a Minneapolis freelance writer and frequent contributor to Minnesota Medicine.