Implementing human factors in anaesthesia.

Abstract

We were delighted to see the work of Kelly et al. [1] in formalising the utilisation of human factors (HF) principles in anaesthesia. Whilst this dialogue has been ongoing for more than 20 years and draws largely from the limited sub-discipline of non-technical skills, it is encouraging to see the beginnings of a broader view that encompasses the wider and richer application of systems thinking that professional HF practitioners utilise. However, we lament the insufficient representation of HF professionals involved in the coproduction of these guidelines and the absence of any reference to professionally qualified HF expertise. Whilst we applaud the systematic attempt to apply the Delphi method to develop the new guidelines, we observe that only three out of the 15 participants were HF specialists, of whom two focus primarily on behavioural safety [2]. Had the team reflected a more balanced range of HF expertise, for example in user experience, accident analysis, resilience engineering or naturalistic decision-making, we believe a very different set of recommendations would have been produced. Similarly, while the hierarchy of controls model is an encouraging attempt to acknowledge the inadequacies of behavioural approaches, it overlooks the complex interactions within sociotechnical systems and the importance of context, where more systemic rigidity may be helpful (for example during a theatre-based elective case) or harmful (for an emergency outside theatres). Indeed, it seems odd to see ‘design’ as separate from, and equivalent to, ‘barriers’, ‘mitigations’ and ‘education and training’. An arguably more insightful and widely used model for framing complex sociotechnical interactions in healthcare, the systems engineering initiative in patient safety (SEIPS), is only briefly mentioned in relation to incident analysis. In seeking simplicity for clinicians, and not providing a balanced view from qualified HF professionals, at best the guidelines only scratch the surface of HF and misrepresent many years of clinical HF research. Human factors are not new. The worldwide failure of healthcare systems to employ sufficient engineering, psychology and HF expertise has been observed multiple times by multiple groups over more than a decade [3]. This has unquestionably held up progress in safety and other aspects of clinical performance improvement [3]. We agree with the excellent editorial from Marshall that the application of HF in healthcare is “possibly the most complex of sociotechnical human endeavours ever attempted”, and reasonably observe that this is unlikely to be solved in the absence of professional expertise and funding [4]. Just like clinical work, success in HF practice cannot be reduced to education, checklists, technologies or recipes alone. There are many subtleties to be understood, trade-offs to be balanced and judgements to be made. To address this complexity, just like clinicians, HF professionals study for three or more years, usually focusing their practice in a sub-specialty over many more years through apprenticeship and collaboration, with continuous development a strong feature of professionalism. To build on the promise of HF presented here, collaborations between clinicians and full-time HF professionals need to be far more widely established than they are now [5]. Our hope is that, if we cannot have a chartered HF professional in every hospital, at least there should be access to one. Internationally, the growing number of clinically embedded HF professionals and HF-interested clinicians in the USA led to the development of a supporting network that has over 200 members, many from the UK and Australia. At a local level, simulation centres have begun to employ HF professionals to bridge this critical clinical-HF gap. Others have embedded them within Transformation Departments to provide the HF perspective to improvement programmes, as well as support the implementation of suitable HF programmes (e.g. www.scream-safety.com). This, of course, requires investment in clinicians, HF professionals and infrastructure; and before that, acknowledgement that the expertise cannot be grown only from within. So, while we celebrate the guidelines, and the long journey that all of us have taken to get to this point, in order to accelerate this work, and not repeat the mistakes of the last 20 years, clinicians need to accept that they cannot do it alone.