Human Factors Engineering for the Pediatric Hospitalist

Abstract

As pediatrics hospitalists, we care for a diverse population of hospitalized children with increasing acuity and complexity in large, multidisciplinary medical teams. In this Method/ology paper, we summarize how human factors engineering (HFE) can provide a framework and tools to help us understand and improve our complex care processes and resulting outcomes. First, we define and discuss the three domains of HFE (i.e., physical, cognitive, and organizational) and offer examples of HFE’s application to pediatric hospital medicine. Next, we highlight an HFE-based framework, the Systems Engineering for Patient Safety model, which conceptualizes how our work system shapes healthcare processes and outcomes. We provide tools for leveraging this model to better understand the context in which our work is done, which, consequently, informs how we design our systems and processes to improve the quality and safety of care. Finally, we outline the basics of human-centered design and highlight a case study of a project completed in a pediatric hospital setting focused on making rounds more family-centered. In addition, we provide resources for those interested in learning more about HFE.

INTRODUCTION

As pediatric hospital systems become increasingly complex—made up of higher acuity patients cared for by larger multidisciplinary care teams and reliant on advanced medical and health information technologies—new paradigms for ensuring high quality care delivery are required.¹ Human factors engineering (HFE) has gained traction in healthcare by introducing the concept of systems level thinking, for example by transitioning from the traditional view of medical mistakes as individual failures to the notion that errors arise from complex interactions within healthcare systems.² While HFE has long informed the design of systems within other safety-critical industries, notably aerospace and aviation, its influence within healthcare is more recent and growing rapidly.

Whether you have been part of a quality improvement project or patient safety initiative, chances are you have encountered many complex interactions between humans and the systems in which they work. These interactions are likely either tangentially related or significantly interwoven with the desired outcomes of your project. HFE can provide a framework and tools to understand the important components of these systems and ways to leverage their interactions to improve care processes and outcomes. Whether you are interested in improving medication safety, preventing hospital-acquired infections, implementing new clinical guidelines, or enhancing care transitions, it is likely that the incorporation of HFE principles will help to ensure your project’s success.

In this paper, we present a basic primer on HFE, focusing on the importance of accounting for human-systems interactions and introducing human-centered design. The intended audience is the pediatric hospitalist who desires to improve care processes and/or outcomes in their workplace and is curious about how HFE can help them accomplish that goal. We hope to offer a pragmatic approach to getting started with HFE and resources for further study.

What is human factors engineering?

HFE, also referred to as human factors or ergonomics, is the scientific discipline devoted to understanding the interactions between people and the systems in which they work and subsequently designing systems that jointly optimize people’s well-being and system performance.³ The International Ergonomics Association defines three domains of HFE: physical, cognitive, and organizational.³ Each domain has important contributions to make in healthcare. Physical ergonomics considers the anatomical, physiological, and biomechanical capacities of people in the design of tasks (e.g., the ideal weight that a human can safely lift), tools (e.g., dimensions of chairs, grips of surgical instruments), and the physical environment (e.g., hospital floorplans, lighting, air quality). Cognitive ergonomics considers the mental capacities of people (e.g., perception, memory, reasoning) and their impact on interactions with a system (e.g., a healthcare worker’s workload or the usability of a medical device). Finally, organizational ergonomics or macroergonomics considers a person’s work system (i.e., their work tasks, the tools and technologies they work with, and their organizational and physical environments) and how interactions between aspects of the work system shape outcomes (e.g., how the quality of patient handoffs or use of the electronic health record impacts patient safety). Here, we focus on organizational ergonomics, which can play a pivotal role in understanding and improving complex healthcare systems, like the pediatric inpatient setting.⁴

Work systems shape healthcare processes and outcomes

As mentioned above, understanding the work or sociotechnical system surrounding a person (e.g., healthcare worker, patient, family) is an important part of an HFE-approach to improving care. There are multiple frameworks that explicitly account for system components and their interactions to better understand how and why specific outcomes (e.g., patient safety) result.⁴ One of the most influential work systems frameworks used in healthcare is the Systems Engineering Initiative in Patient Safety (SEIPS) model (Figure 1).⁵ SEIPS places people (e.g., healthcare worker, patient, family) at the center of a work system and describes how they use specific tools and technologies to conduct tasks within their organizational and physical environment.⁵ Together these components and their interactions form the work system which shapes work processes and, ultimately, influences outcomes for patients and caregivers (professional and otherwise). Therefore, to improve outcomes, one must evaluate the various components of the work system and their interactions.

Figure 1.

Adapted Systems Engineering for Patient Safety (SEIPS) model⁵

There are many existing tools that can help you better understand the work system for your particular project. Holden and Carayon⁶ outline seven simple tools to systematically identify important work system components and interactions. One of these tools is the PETT (People, Environments, Tools, and Tasks) scan. This is a simple checklist and documentation tool that can help you identify individual components and interactions that can either hinder or help people do their work effectively. Once you have developed a deeper understanding of the current work system for your project, you can progress to (re)designing that system.

Human-centered design

Human-centered design (HCD) applies HFE principles to develop systems that are “usable and useful by focusing on the users, their needs, and requirements.”^9vi The first step in any HCD process is to plan the process, including setting a design objective and selecting the scope (Figure 2, Step 1). Often, the design objective and project scope will be influenced by what can practically be studied (e.g., a care process that can reasonably be observed) and done (e.g., an objective that is likely achievable given the time, money, and expertise of the team).

Figure 2.

Human-centered design process⁹

Second, one must understand the work system or context that will be (re)designed (Figure 2, Step 2). Tools such as a PETT scan (see prior section) will help you accomplish this step. An essential aspect of specifying the context is to identify who is involved and should be included in the design process. Depending on the context, the who may include end-users of the design (e.g., clinicians, patients) and other stakeholders in the design and/or its implementation (e.g., managers or other leaders, information technologists). In the next step in the HCD process, one should articulate the requirements of the different users or people involved (Figure 2, Step 3). Frequently, the output of this step holds conflicting perspectives and needs that must be reconciled.^10,11

One method of approaching the HCD process is to use participatory methods,^12,13 wherein the people who will be impacted by the design (e.g., end-users, stakeholders) contribute to the process of turning user requirements into potential solutions (Figure 2, Step 4). Once potential solutions have been identified, they can be developed and evaluated against the user requirements in an iterative process (Figure 2, Step 5). Once a design is produced that sufficiently meets user requirements, the design can be implemented (Figure 2, Step 6). In practice, iteration happens well into the implementation of a design as the outcomes of the system are monitored. The need for continuous design iteration is especially relevant for ensuring high quality health information technologies.¹⁴

Human factors engineering in action: a case study

Here we provide an example of employing a human-centered, participatory design process to redesigning family-centered rounds at one children’s hospital.¹⁵ Our design objective was to improve the way we engaged families during rounds and, in turn, enhance patient safety (Step 1). From a HFE standpoint, we recognized that any changes we made to rounds would need to be designed for and integrated within our complex inpatient work system. Specifically, we would need to account for the work performed by the multiple people on rounds (e.g., parents, physicians, nurses, pharmacists, learners) and how they interacted with tools and technology (e.g., computers on wheels, electronic health record, pagers) to accomplish their daily tasks across multiple inpatient units.

We first observed and outlined our current rounding process using a PETT scan guided by the SEIPS work system components (Step 2). We then elicited 21 ideas (i.e., user requirements) for improving family engagement during rounds from families of hospitalized children and members of their healthcare team (Step 3). Using a participatory approach, we gathered a team of stakeholders representing those who participate in rounds.¹² We surveyed them on their perception of the impact of each of these 21 ideas on family engagement and assembled the highest impact ideas into 3 potential interventions. We piloted each of the three interventions and surveyed stakeholders again on the feasibility and sustainability of each. The most feasible and sustainable intervention was identified as a checklist of recommended activities that should be completed during every rounding session (Step 4).

Finally, to evaluate whether the checklist intervention met the design objective, we observed checklist use and stakeholder perspectives after implementation (Step 5). We subsequently demonstrated that performance of checklist items improved family engagement and parent perceptions of safety during their child’s hospitalization.¹⁵ More information about this HCD process, the family-centered rounds checklist, and supporting materials can be found at: www.hipxchange.org/FamilyRounds. Other recent examples of human-centered design in pediatrics include the development of shared displays to support teamwork during care transitions⁷ and the development of a mobile health application to support family-delivered enteral tube care.⁸

How to incorporate human factors in your work

In this paper, we introduced one HFE framework – the SEIPS model – to understand the complex interactions in healthcare systems that shape outcomes for people (e.g., parents, physicians, nurses, pharmacists, learners). We then highlighted tools to operationalize the SEIPS model as part of a human-centered, participatory design process and provided an example. We must acknowledge that this is an intentionally abbreviated introduction to the HFE field. The embedded references include additional information outside the scope of this introductory overview – we encourage interested readers to explore them!

While HFE is increasingly emphasized in medical education and thus has increased the ability and expertise of clinicians to incorporate these principles into their work¹, partnering with an HFE expert may be a more expedient way to access in-depth HFE experience. In other words, a good physician may not know all the answers, but knows when to ask for help. Do not hesitate to engage an HFE practitioner, scientist, or researcher in your work. And, given healthcare systems are increasingly employing HFE experts, there may be HFE experts closer to you than you first imagined. If not, we suggest a variety of resources to identify potential collaborators (Table 1).

Table 1.

Resources to Identify Human Factors Engineering (HFE) Experts

Organizations*	- Health Care Technical Group of the Human Factors and Ergonomics Society - https://www.hctg.hfes.org/ - Human Factors and Ergonomics Society (HFES) - https://www.hfes.org/ - Healthcare Ergonomics Technical Committee of the International Ergonomics Association - https://iea.cc/member/healthcare-ergonomics/ - International Ergonomics Association (IEA) - https://iea.cc/ - Human Factors Transforming Healthcare - https://www.hfthnetwork.org/ - International Society for Quality in Healthcare - https://isqua.org/
Conferences*	- International Annual Meeting of the Human Factors and Ergonomics Society - International Symposium on Human Factors and Ergonomics in Health Care - Healthcare Systems Ergonomics and Patient Safety - Organizational Design and Management Conference - International Ergonomics Association Triennial Congress
Journals	HFE in healthcare:  - Human Factors in Healthcare  - IISE Transactions on Healthcare Systems Engineering  - International Journal for Quality in Health Care  - JMIR Human Factors HFE across domains, including healthcare:  - Applied Ergonomics  - Cognition, Technology and Work  - Ergonomics  - Ergonomics in Design  - Human Factors  - IISE Transactions on Occupational Ergonomics and Human Factors  - Theoretical Issues in Ergonomics

^*These are focused on the United States and overarching international organizations. Other nation-level HFE societies may be useful in other countries (e.g., the Chartered Institute for Ergonomics and Human Factors in the United Kingdom).

Conclusion

HFE provides useful frameworks, approaches, methodologies, tools, and principles to improve quality and safety in healthcare. In particular, the HFE-based concept of the work system can be useful in understanding the contextual factors that shape care processes and influence outcomes. The SEIPS model combined with a human-centered, participatory design approach can guide improvement efforts. However, an important aspect of these models is the feedback loop – as you (re)design the work system and process, you must continue to gather feedback on system performance and iteratively and continuously improve your design. In doing so, you may reach a point that additional expertise is needed – do not hesitate to reach out to collaborate with HFE experts. Together, we can improve systems to keep kids and health care workers safe, healthy, and happy.

Take home points.

• Human factors engineering is the science of jointly optimizing system outcomes and people’s well-being.

• The systems that people work in shape healthcare processes and outcomes.

• Identifying the work system components and their interactions that matter is key to improving healthcare processes and outcomes.

• Human-centered design is an iterative process that centers the needs of people.

• Ask for help; there are human factors experts who want to collaborate.

Abbreviations:

HFE

Human factors engineering

SEIPS

Systems engineering initiative for patient safety

HCD

Human-centered design