Human factors systems approach to healthcare quality and patient safety

Highlights

• The SEIPS model of work system and patient safety is a useful systems approach to healthcare quality and patient safety.

• The SEIPS model can be used for research and improvement activities for improving healthcare quality and patient safety.

• Balancing the work system is a key principle to improve healthcare quality and patient safety.

Abstract

Human factors systems approaches are critical for improving healthcare quality and patient safety. The SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety is a human factors systems approach that has been successfully applied in healthcare research and practice. Several research and practical applications of the SEIPS model are described. Important implications of the SEIPS model for healthcare system and process redesign are highlighted. Principles for redesigning healthcare systems using the SEIPS model are described. Balancing the work system and encouraging the active and adaptive role of workers are key principles for improving healthcare quality and patient safety.

Introduction

In the early 1960's Chapanis and Safren¹ (Chapanis and Safrin, 1960, Safren and Chapanis, 1960a, Safren and Chapanis, 1960b) conducted one of the first human factors and ergonomics (HFE) studies on medication safety. The researchers used the critical incident technique to examine medication errors. They identified a total of 178 medication administration errors over a period of seven months: (1) wrong patient, (2) wrong dose of medication, (3) extra unordered medication, (4) medication not administered, (5) wrong drug, (6) wrong timing of medication administration, and (7) incorrect medication route. A range of work system factors contributed to medication errors, such as failure to follow required checking procedures, and verbal or written communication problems. This study highlighted the importance of work system issues in medication safety. However, it was not until the publication of the US Institute of Medicine report “To Err is Human: Building a Safer Health System” in 1999 (Kohn et al., 1999) that HFE and its systems approach were recognized as critical for patient safety across all healthcare domains.²

Healthcare professionals, leaders and organizations understand the importance of HFE as a scientific discipline that can produce knowledge to redesign healthcare systems and processes and improve patient safety and quality of care (Carayon et al., 2013; Gurses et al., 2012b; Institute of Medicine, 2012; Leape et al., 2002; Pronovost and Goeschel, 2011; Pronovost and Weisfeldt, 2012). For instance, the World Health Organization curriculum on patient safety includes 11 topics, among which two are core to HFE: (a) topic 2: What is human factors engineering, and why is it important to patient safety?, and (b) topic 3: Understanding systems and the impact of complexity on patient care (Walton et al., 2010). The US Agency for Healthcare Research and Quality (AHRQ) promotes an HFE approach to the design of health information technology (IT) (NRC Committee on the Role of Human Factors in Home Health Care, 2010, 2011) and has published a variety of guidance documents on using HFE systems models to analyze patient safety events in healthcare delivery (Henriksen et al., 2008, 2009). Various IOM reports have called for the incorporation of HFE, and of systems approaches generally, into health and healthcare research, design, and policy (Grossman et al., 2011; Institute of Medicine, 2001, 2004, 2006, 2012; Reid et al., 2005).

Given the complexity of healthcare (Carayon, 2006), HFE interventions that do not consider issues across the whole system, including organizational factors, are unlikely to have significant, sustainable impact on patient safety and quality of care. For instance, improving the physical design of a medical device or the cognitive interface of health IT is important; but without understanding the organizational context in which these technologies are used, workers may develop work-arounds, the tools may not be used safely, and health IT may be usable but not useful. Therefore, an HFE systems approach to healthcare quality and patient safety should include organizational HFE or macroergonomic considerations.

We have proposed an HFE systems approach to address patient safety and other quality of care problems (see Fig. 1). The SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety (Carayon et al., 2006b) is based on the macroergonomic work system model developed by Smith and Carayon (Carayon, 2009, Carayon and Smith, 2000, Smith and Carayon-Sainfort, 1989, Smith and Carayon, 2001), and incorporates the Structure-Process-Outcome (SPO) model of healthcare quality (Donabedian, 1978). The SPO model of Donabedian (1978) is the most well-known model of healthcare quality. The integration of the work system model with this prominent model of healthcare quality increases the acceptability of the SEIPS model by the healthcare community. In this paper, we first describe the SEIPS model of work system and patient safety and its research and practical applications. We then emphasize the principle of ‘balance’ and focus on system interactions that need to be considered in order to make significant progress in healthcare quality and patient safety.