SIMPLE tool in Simple Way

1
SIMPLE tool in Simple Way

• Pongtorn Kietdumrongwong, MD

2
Quality is too hard to achieve ?

• Too many works
• Too many documents
• Too many concepts
• Too many tools
• Too many training
• Too many people involved
• Too much cost to invest

3
To ease QI process

• Human factors engineering is about designing the
  workplace and the equipment in it to accommodate
  for limitations of human performance

4
Human factors definition

• The study of all the factors that make it easier
  to do the work in the right way
• Apply wherever humans work
• Also sometimes known as ergonomics

5
Human factors

• Importance of human factors has been recognized
  for a long time in
• aviation
• nuclear power

6
Importance in health care?

• Only recently been acknowledged as an essential
  part of patient safety
• A major contributor to adverse events in health
  care
• All health-care workers need to have a basic
  understanding of human factors principles

7
Human factors experts

• Design improvements in the workplace and the
  equipment to fit human capabilities and
  limitations
• Make it easier for the workers to get the work
  done the right way
• Decrease the likelihood of errors occurring

8
Examples

• order medications electronically
• hand off information
• move patients
• If all of these tasks become easier for the
  health-care
• provider, then patient safety can improve.

9
EXAMPLE

• I have talked to much theory !

10
Avoidable confusion is everywhere
US Department of Veteran affairs
11
Health care is increasingly complex
Gaba
12
Human factors design principles

• Psychomotor
• Hands

• Input Devices
• Buttons

INTERFACE
Senses - Vision - Hearing
Output - Display - Sound
US Department of Veteran affairs
13
Human factors

• acknowledges
• the universal nature of human fallibility
• the inevitability of error
• assumes that errors will occur
• designs things in the workplace to try to
  minimize the likelihood of error or its
  consequences

14
Traps in health care?

• Look-alike and sound-alike pharmaceuticals
• Logistic and Traffic design
• Equipment design
• e.g. infusion pumps

15
Because the human brain is .

• very powerful
• very flexible
• good at finding shortcuts (fast)
• good at filtering information
• good at making sense of things

16

• Sometimes though our brain is
• too clever

17
Are the lines crooked or straight?
Optillusions.com
18

• Look at the chart
• Say the colour of the word, not the word itself

Why is it hard?
Optillusions.com
19
The context of health care

• When errors occur in the workplace the
  consequences can be a problem for the patient
• a situation that is relatively unique to health
  care

20
Situations associated with an increased risk of
error

• unfamiliarity with the task
• inexperience
• shortage of time
• inadequate checking
• poor procedures
• poor human equipment interface

Especially if combined with lack of supervision
21
Apply human factors thinking to your work
environment

1. Avoid reliance on memory
2. Make things visible
3. Review and simplify processes
4. Standardize common processes and procedures
5. Routinely use checklists
6. Decrease the reliance on vigilance

22
SIMPLE AS A TOOL TO REDUCE ERROR
23
Checklist
24
Thai International Health Care Standard Training
Center
-----Fall Risk-----
25
System Flow
26
Screen Shot (Login)
www.thaititc.com
27
Screen Shot (Authorize)
www.thaititc.com
28
Screen Shot (Fall Risk)
www.thaititc.com
29
Screen Shot (Fall Risk)
www.thaititc.com
30
Screen Shot (Fall Risk)
www.thaititc.com
31
Screen Shot (Fall Risk)
www.thaititc.com
32
Screen Shot (Fall Risk)
www.thaititc.com
33
Screen Shot (Fall Risk)
www.thaititc.com
34
THANK YOU